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Essentials of 
Mental Health 

Concepts of Care in Evidence-Based Practice 
Mary C. Townsend 

jg g/Davisplafr 

Davie Plijcfadavicrnm 


This page intentionally left blank 

Essentials of 

Mental Health 




Mary C. Townsend, dsn, pmhcns-bc 

Clinical Specialist/Nurse Consultant 
Adult Psychiatric Mental Health Nursing 

Former Assistant Professor and 

Coordinator, Mental Health Nursing 

Kramer School of Nursing 

Oklahoma City University 

Oklahoma City, Oklahoma 

i RA. Davis Company • Philadelphia 

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F.A. Davis Company 
1915 Arch Street 
Philadelphia, PA 19103 

Copyright © 201 1 by F.A. Davis Company 

Copyright © 2011 by F.A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be 
reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, 
recording, or otherwise, without written permission from the publisher. 

Printed in the United States of America 

Last digit indicates print number: 1098765432 1 

Publisher, Nursing: Robert G. Martone 

Director of Content Development: Darlene D. Pedersen 

Senior Project Editor: Padraic J. Maroney 

Cover Design: Carolyn O'Brien 

As new scientific information becomes available through basic and clinical research, recommended treatments and drug thera- 
pies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and 
in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for 
errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to 
the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional 
standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to 
check product information (package inserts) for changes and new information regarding dose and contraindications before 
administering any drug. Caution is especially urged when using new or infrequently ordered drugs. 

Library of Congress Cataloging-in-Publication Data 

Townsend, Mary C, 1941— 
Essentials of psychiatric/mental health nursing : concepts of care in evidence-based practice / Mary C. Townsend. — fifth ed. 

p. ; cm. 
Includes bibliographical references and index. 
ISBN-13: 978-0-8036-2338-5 
ISBN-10: 0-8036-2338-0 
1. Psychiatric nursing. I. Title. 

[DNLM: 1. Psychiatric Nursing — methods. 2. Mental Disorders — nursing. WY 160 T749e 2011] 
RC440.T689 2011 
616.89'0231— dc22 


Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by 
F.A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, pro- 
vided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations 
that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users 
of the Transactional Reporting Service is: 8036-2338-5/11 + $.25. 

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To my best friend, Jimmy 

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9/1/10 2:54:10 PM 


Lois Angelo, MSN, APRN, BC 

Assistant Professor 

Massachusetts College of Pharmacy and Health 

Boston, Massachusetts 

Linda Blair, BSN, RN 

Nursing Instructor 

Central Carolina Community College 

Sanford, North Carolina 

Debra DeVoe, RN, MSN, NE-BC 

Nursing Instructor 
Our Lady of Lourdes 
Camden, New Jersey 

Donna A. Enrico, MBS, BSN, RN 

Clinical Instructor 

College of Southern Nevada 

Las Vegas, Nevada 

Elizabeth Fife, MSN, RN, CNS, CPN 

Associate Professor 
Louisiana Tech University 
Ruston, Louisiana 

Patricia J. Hefner, MSN, RN-BC 

Faculty; Course Coordinator of Psychiatric 

Mental Health Nursing 
Heritage Valley Sewickley 
Moon, Pennsylvania 

Sharon A. Henle, EdD, ANP, RHIA, CNE 

Assistant Professor of Nursing 
Farmingdale State College 
Farmingdale, New York 

Jennifer E. Herrold, RN, MSN, CRNP 


Thomas Jefferson University 

Danville, Pennsylvania 

Beverly J. Howard, MSN, RN, FNP 


Alvin Community College 

Alvin, Texas 

Katherine M. Howard, MS, RN-BC 

Nursing Instructor 

Middlesex County College Nursing Program, 

Raritan Bay Medical Center 
Edison, New Jersey 

Janet K. Johnson, MBA, MSN, RN 

Nursing Coordinator 

Fort Berthold Community College 

New Town, North Dakota 

Rebecca King, RN, MSN, PMHCNS-BC 

Division Chair for Nursing and Allied Health 
University of Arkansas, Community College of 

Batesville, Arkansas 

Jan E. Lawrenz Blasi, MSN, RN 

Nursing Instructor 

Chandler School of Nursing and Allied Health, 

Pratt Community College 
Pratt, Kansas 

Anne Marie Leveille, RN, MSN, MPH 

Assistant Professor 
Medgar Evers College 
Brooklyn, New York 

Tamar Lucas, BSN, MSN, RN, BC 

Nursing Instructor 
Itawamba Community College 
Fulton, Mississippi 

Jana S. Martin, MS, RN, CNE 

Division Chair, Allied Health Services 
OSU Institute of Technology 
Okmulgee, Oklahoma 

Renee Menkens, RN, MS 

Assistant Professor 

Southwestern Oregon Community College 

Coos Bay, Oregon 

Susan M. Reading-Martin, 

Nursing Faculty 

Western Nebraska Community College 

Scottsbluff, Nebraska 


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Donna F. Rye, MSN, RN 

Assistant Professor 
Cox College 
Springfield, Missouri 

Karen B. Silva, RN, MSN, MFN, BC 

Nursing Faculty 
Keiser University 
Sarasota, Florida 

Alexandra Winter, RN, MSN 

Assistant Director of Nursing 
Metropolitan Community College 
Omaha, Nebraska 

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A very special thank you to: 

Cathy Melfi Curtis, MSN, RN-BC, Psychiatric Mental Health Nursing, Trident Technical 
College, Charleston, South Carolina, for her outstanding work in preparation of the student 

and instructor test banks that accompany this textbook, and to 

Cathy Melfi Curtis and Carol Norton Tuzo, MSN, RN-BC, Psychiatric Mental Health 

Nursing, Trident Technical College, Charleston, South Carolina, for their collaboration 

in preparing the PowerPoint presentation to accompany this textbook. 

Sincere thanks also go to: 

Robert G. Martone, Publisher, Nursing, F.A. Davis Company, for your sense of humor and 

continuous optimistic outlook about the outcome of this project. 

PadraicJ. Maroney, Senior Project Editor, Nursing, F.A. Davis Company, for all your help and 

support in preparing the manuscript for publication. 

Linda Kern, Project Manager, Progressive Publishing Alternatives, for your support and compe- 
tence in the final editing and production of the manuscript. 

The nursing educators, students, and clinicians, who provide critical information about the 
usability of the textbook, and offer suggestions for improvements. Many changes have been 

made based on your input. 

To those individuals who critiqued the manuscript for this edition and shared your ideas, opinions, 
and suggestions for enhancement. I sincerely appreciate your contributions to the final product. 

Mary C Townsend 


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The fifth edition of Essentials of Psychiatric/Mental 
Health Nursing is published at a time of continued 
change and turmoil in the nursing profession. The 
United States is in the midst of a nursing shortage that 
is expected to intensify as baby boomers age and the 
need for health care grows. Compounding this prob- 
lem is a shortage of nursing faculty. Qualified appli- 
cants to nursing schools are being turned away because 
of insufficient numbers of faculty. In 2005, the U.S. 
Department of Labor awarded several million dollars 
in grants to address the nurse faculty shortage. These 
new faculty members need assistance in transitioning 
to the role of nursing educator. 

The target audience for Essentials 5e includes both 
associate degree and baccalaureate programs. The 
duration of most psychiatric nursing rotations is 5 to 
10 weeks. This leaves little time for extraneous mate- 
rial, and faculty must concentrate on the "essential" 
concepts related to nursing of psychiatric clients. This 
textbook is a presentation of those essential concepts. 

Because most psychiatric nursing students feel 
uncomfortable and somewhat insecure with the com- 
munication aspects of psychiatric nursing, a new em- 
phasis on therapeutic communication is included in 
the Essentials 5e. Communication strategies have been 
expanded within the interventions included in the care 
plans. These "communication interventions" are iden- 
tified by the icon (%). 

It is our goal to stay on the cutting edge of nursing 
education. So with this in mind, the topic of Quality 
and Safety Education for Nurses (QSEN) is addressed 
in this edition. In February 2007, The Robert Wood 
Johnson Foundation (RWJF) awarded a grant to the 
University of North Carolina at Chapel Hill School of 
Nursing to develop a curriculum on quality and safety 
for nursing schools. The Institute of Medicine (IOM), 
in its 2003 report, Health Professions Education: A Bridge 
to Quality, challenged faculties of medicine, nurs- 
ing, and other health professions to ensure that their 
graduates have achieved a core set of competencies in 
order to meet the needs of the 2 1st century health-care 
system. These competencies include providing patient- 
centered care, working in interdisciplinary teams, employing 
evidence-based practice, applying quality improvement, and 
utilizing informatics. 

Educational associations and accrediting bodies are 
recommending the inclusion of these competencies 

in the curricula of nursing schools. Historically, qual- 
ity care and patient safety have been core concepts of 
nursing and nursing education. However, it has been 
suggested that ideas for teaching quality and safety 
competencies has been sorely lacking. Under the lead- 
ership of Principal Investigator Linda R. Cronenwett, 
the IOM competencies have been adapted for nurs- 
ing in the hope that they can serve as guidelines to 
curricular development, and ultimately to "provide a 
framework for regulatory bodies that set standards for 
licensure, certification, and accreditation of nursing 
education programs." The work of Cronenwett and 
her associates, including competency definitions and 
an outline of required knowledge, skills, and attitudes 
associated with each, was published in Nursing Outlook, 
55(3), and may be found on the website http://www 

Definitions of the quality and safety competencies as 
they apply to nursing include the following: 

1. Patient-centered care. Recognize the patient or 
designee as the source of control and full partner 
in providing compassionate and coordinated care 
based on respect for patient's preferences, values, 
and needs. 

2 . Teamwork and collaboration. Function effectively 
within nursing and inter-professional teams, foster- 
ing open communication, mutual respect, and shared 
decision making to achieve quality patient care. 

3. Evidence -based practice. Integrates best cur- 
rent evidence with clinical expertise and patient/ 
family preferences and values for delivery of opti- 
mal health care. 

4. Quality improvement. Use data to monitor the 
outcomes of care processes and use improvement 
methods to design and test changes to continu- 
ously improve the quality and safety of health-care 

5. Safety. Minimizes risk of harm to patients and pro- 
viders through both system effectiveness and indi- 
vidual performance. 

6. Informatics. Use information and technology to 
communicate, manage knowledge, mitigate error, 
and support decision making. 

Within selected chapters, this textbook includes a 
number of boxes entitled "QSEN Teaching Strategy." 
These activities arm the instructor and the student 


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with guidelines for attaining the knowledge, skills, 
and attitudes necessary for achievement of quality and 
safety competencies in nursing. 


All content has been updated to reflect current 
state of the discipline of nursing. 

Updated NANDA terminology based on Nursing 
Diagnoses: Definitions and Classification 2009-2011 has 
been used throughout the text. 

Homework assignments. At the beginning of 
each chapter, following the objectives, a new section 
has been added entitled "Homework Assignment." It 
is much easier to teach when students come prepared 
and have read the text before class. However, many 
students are reluctant readers. One way to encourage 
students to read before class is to assign homework due 
before class based on the day's topic. Homework ques- 
tions need to count toward the grade but they don't 
have to count a lot. Students are motivated by even a 
small number of points because they know they can 
complete homework successfully if they try. Grading 
criteria should be clear, and to minimize grading time, 
homework could also be assigned "pass-fail." Home- 
work questions are straightforward and, because stu- 
dents will not yet have had a chance to ask questions 
in class on the topic, are written at the knowledge and 
comprehension levels rather than at the application 
and analysis levels. 

Psychopharmacology does not appear as a separate 
chapter in the fifth edition. Overview content has been 
moved to Chapter 3 "Biological Implications." Content 
related to specific medications appears in the diagnosis 
chapter to which the medication applies. This should 
facilitate understanding of the medication, as well as 
the study process for the student. All new medications 
since publication of the previous edition are included. 

There is a new emphasis on communication 
techniques in the fifth edition. 

Communication strategies have been expanded 
within the interventions included in the care plans. 
These "communication interventions" are identified 
by the icon (§). 

Boxes entitled "QSEN Teaching Strategy" ap- 
pear within selected chapters. These activities pro- 
vide the instructor and the student with guidelines for 
attaining the knowledge, skills, and attitudes necessary 
for achievement of quality and safety competencies in 

Review questions at the end of each chapter have 
been updated to reflect the NCLEX format. Summa- 
ries now appear as "key points" from the chapter. 

The Mental Status Assessment has been expand- 
ed to include psychosocial assessment questions to fa- 
cilitate the assessment process for the student. 

Tables entitled "Assigning Nursing Diagnoses 
to Behaviors Commonly Associated With (specific 
diagnosis)" have been added to diagnosis chapters. 

Sample Case Studies and Care Plans have been 
included at the end of each of the diagnosis chapters. 

The chapter on mood disorders has been divided 
into two separate chapters: 

"Mood Disorders — Depression" and "Mood 
Disorders — Bipolar Disorder." 

The neurobiology of ADHD has been added to 
this edition. 

New content on fetal alcohol syndrome and valid- 
ity therapy is included. 

A concept care map for dementia has been added. 


The concept of holistic nursing is retained in the 
fifth edition. An attempt has been made to ensure that 
the physical aspects of psychiatric/mental health nurs- 
ing are not overlooked. In all relevant situations, the 
mind-body connection is addressed. 

Nursing process is retained in the fifth edition as 
the tool for delivery of care to the individual with a 
psychiatric disorder or to assist in the primary pre- 
vention or exacerbation of mental illness symptoms. 
The six steps of the nursing process, as described in 
the American Nurses Association Standards of Clini- 
cal Nursing Practice are used to provide guidelines for 
the nurse. These standards of care are included for the 
Diagnostic and Statistical Manual of Mental Disorders, 
Fourth Edition, Text Revision (DSM-IV-TR) diagnoses, 
as well as the aging individual, the bereaved individual, 
victims of abuse and neglect, and as examples in several 
of the therapeutic approaches. The six steps include: 

• Assessment: Background assessment data, includ- 
ing a description of symptomatology, provides an 
extensive knowledge base from which the nurse 
may draw when performing an assessment. Several 
assessment tools are also included. 

• Diagnosis: Analysis of the data is included, from 
which nursing diagnoses common to specific psy- 
chiatric disorders are derived. 

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• Outcome Identification: Outcomes are derived 
from the nursing diagnoses and stated as measur- 
able goals. 

• Planning: A plan of care is presented with selected 
nursing diagnoses for the DSM-IV-TR diagnoses, 
as well as for the elderly client, the bereaved in- 
dividual, victims of abuse and neglect, the elderly 
homebound client, and the primary caregiver of the 
client with a severe and persistent mental illness. 
The planning standard also includes tables that list 
topics for educating clients and families about men- 
tal illness. Concept map care plans are included for 
all major psychiatric diagnoses. 

• Implementation: The interventions that have 
been identified in the plan of care are included 
along with rationales for each. Case studies at the 
end of each DSM-IV-TR chapter assist the student 
in the practical application of theoretical material. 
Also included as a part of this particular standard 
is Unit II of the textbook: "Psychiatric/Mental 
Health Nursing Interventions." This section of 
the textbook addresses psychiatric nursing inter- 
vention in depth, and frequently speaks to the dif- 
ferentiation in scope of practice between the basic 
level psychiatric nurse and the advanced practice 
level psychiatric nurse. 

• Evaluation: The evaluation standard includes a 
set of questions that the nurse may use to assess 
whether the nursing actions have been successful in 
achieving the objectives of care. 

Other Features 

Internet references for each DSM-IV-TR diagnosis, 
with website listings for information related to the 

Tables that list topics for client/family education 
(clinical chapters) 

Boxes that include current research studies with 
implications for evidence-based nursing prac- 
tice (clinical chapters) 

Assigning nursing diagnoses to client behaviors 
(diagnostic chapters and Appendix C) 

Taxonomy and diagnostic criteria from the DSM- 
IV-TR (2000) are used throughout the text. 

All references have been updated throughout the 
text. Classical references are distinguished from 
general references. 

Boxes with definitions of core concepts appear 
throughout the text. 

An E A. Davis/Townsend website that contains addi- 
tional nursing care plans that do not appear in the text, 
links to psychotropic medications, concept map care 
plans, and neurobiological content and illustrations 

A Student CD that contains 270 practice test ques- 
tions, learning activities, concept map care plans, 
and client teaching guides 


Faculty may also find the following teaching aids 
that accompany this textbook helpful: 

Instructor's Resource Disk (IRD). This IRD 

• Approximately 550 multiple-choice questions 
(including new format questions reflecting the 
latest NCLEX blueprint) 

• Lecture outlines for all chapters 

• Learning activities for all chapters (including 
answer key) 

• Answers to the Critical Thinking Exercises from 
the textbook 

• PowerPoint presentations to accompany all 
chapters in the textbook 

• Answers to the Homework Assignment 
questions from the textbook 

It is hoped that the revisions and additions to this fifth 
edition continue to satisfy a need within psychiatric/ 
mental health nursing practice. The mission of this text- 
book has been, and continues to be, to provide both stu- 
dents and clinicians with up-to-date information about 
psychiatric/mental health nursing. The user-friendly 
format and easy-to-understand language, which have 
been retained in this edition, have made this text par- 
ticularly appreciated and often preferred over others. 

Mary C. Townsend 

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Chapter 1: Mental Health and 
Mental Illness 



Mental Health 


Mental Illness 


Physical and Psychological 

Responses to Stress 


Physical Responses 


Psychological Responses 


The DSM-IV-TR Multiaxial 

Evaluation System 


Summary and Key Points 


Chapter 2: Concepts of Personality 

Psychoanalytic Theory 

Structure of the Personality 
Topography of the Mind 
Dynamics of the Personality 
Freud's Stages of Personality 

Relevance of Psychoanalytic 

Theory to Nursing Practice 
Interpersonal Theory 
Sullivan's Stages of Personality 

Relevance of Interpersonal 

Theory to Nursing Practice 
Theory of Psychosocial Development 
Erikson's Stages of Personality 

Relevance of Psychosocial 

Development Theory to 

Nursing Practice 
Theory of Object Relations 

Phase I: The Autistic Phase (Birth 

to 1 Month) 
Phase II: The Symbiotic Phase 

(1 to 5 Months) 












Phase III: Separation-lndividuation 

(5 to 36 Months) 25 
Relevance of Object Relations 

Theory to Nursing Practice 26 
A Nursing Model — Hildegard E. Peplau 26 
Peplau's Stages of Personality 

Development 27 
Relevance of Peplau's Model 

to Nursing Practice 29 

Summary and Key Points 30 

g Chapter 3: Biological Implications 33 

Introduction 34 

Neuorophysiological Influences 34 

The Nervous System 34 

The Neuroendocrine System 43 

Implications for Psychiatric Illness 45 

Schizophrenia 46 

Mood Disorders 46 

Anxiety Disorders 47 

Anorexia Nervosa 47 

Alzheimer's Disease 47 

Diagnostic Procedures Used to Detect 

Altered Brain Function 48 

Electroencephalography 48 

Computerized EEG Mapping 48 

Computed Tomographic Scan 49 

Magnetic Resonance Imaging 49 

Positron Emission Tomography 49 
Single Photon Emission 

Computed Tomography 49 

Psychopharmacology 49 

Historical Perspectives 50 

Role of the Nurse 50 

How Do Psychotropics Work? 51 

Implications for Nursing 53 

Summary and Key Points 55 

Chapter 4: Ethical and Legal Issues 58 

Introduction 59 

Ethical Considerations 60 

Theoretical Perspectives 60 

Ethical Dilemmas 61 

Ethical Principles 61 


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A Model for Making Ethical Decisions 62 
Ethical Issues in Psychiatric/Mental 

Health Nursing 
Legal Considerations 
Nurse Practice Acts 
Types of Law 
Classifications Within Statutory 

and Common Law 
Legal Issues in Psychiatric/Mental 

Health Nursing 
Commitment Issues 
Nursing Liability 
Summary and Key Points 

Chapter 5: Cultural and Spiritual Concepts 
Relevant to Psychiatric/Mental 
Health Nursing 

Cultural Concepts 
How Do Cultures Differ? 



Social Organization 


Environmental Control 

Biological Variations 
Application of the Nursing Process 

Background Assessment Data 

Culture-Bound Syndromes 

Diagnosis/Outcome Identification 


Spiritual Concepts 

Spiritual Needs 

Assessment of Spiritual and Religious 


Diagnoses/Outcome Identification/ 


Summary and Key Points 

U NIT T wo 


Chapter 6: Relationship Development and 

Therapeutic Communication 107 


Conditions Essential to Development 

of a Therapeutic Relationship 

















Phases of a Therapeutic Nurse-Client 




The Preinteraction Phase 



The Orientation (Introductory) Phase 112 


The Working Phase 



The Termination Phase 
Boundaries in the Nurse-Client 





Interpersonal Communication 


The Impact of Preexisting Conditions 115 


Nonverbal Communication 



Therapeutic Communication 





Nontherapeutic Communication 





Process Recordings 



Active Listening 






Summary and Key Points 


Chapter 7: The Nursing Process in 


Psychiatric/Mental Health 







The Nursing Process 






Standards of Practice 






The Nursing Process 






Standards of Practice 


Why Nursing Diagnosis? 



Nursing Case Management 


Critical Pathways of Care 



Applying the Nursing Process 


in the Psychiatric Setting 



Concept Mapping 



Documentation of the Nursing Process 


Problem-Oriented Recording 


Focus Charting 


The PIE Method 


Electronic Documentation 


Summary and Key Points 



The Therapeutic Nurse-Client 

Therapeutic Use of Self 

Chapter 8: Milieu Therapy — The 

Therapeutic Community 

108 Introduction 

Milieu, Defined 

1 08 Current Status of the 

109 Therapeutic Community 




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Chapter 9: 



Basic Assumptions 


Phases of Crisis Intervention: 

Conditions That Promote a 

The Role of the Nurse 


Therapeutic Community 


Phase 1. Assessment 


The Program of Therapeutic 

Phase 2. Planning of Therapeutic 





The Role of the Nurse 


Phase 3. Intervention 


Summary and Key Points 


Phase 4. Evaluation of Crisis 
Resolution and Anticipatory 

Intervention in Groups 






Crisis on the Inpatient Unit: Anger/ 

Functions of a Group 


Aggression Management 


Types of Groups 




Task Groups 


Diagnosis/Outcome Identification 


Teaching Groups 




Supportive/Therapeutic Groups 




Self-Help Groups 


Disaster Nursing 


Physical Conditions That Influence 

Application of the Nursing Process 

Group Dynamics 


to Disaster Nursing 




Background Assessment Data 




Nursing Diagnoses/Outcome 





Curative Factors 




Phases of Group Development 




Phase 1. Initial or Orientation Phase 


Summary and Key Points 


Phase II. Middle or Working Phase 


Chapter 11: Complementary and 

Phase III. Final or Termination Phase 
Leadership Styles 


Psychosocial Therapies 




Complementary Therapies 




Commonalities and Contrasts 




Types of Complementary Therapies 


Member Roles 


Herbal Medicine 




Acupressure and Acupuncture 


The Family as a Group 


Diet and Nutrition 


The Role of the Nurse in Group 

Chiropractic Medicine 




Therapeutic Touch and Massage 


Summary and Key Points 




Intervening in Crises 


Pet Therapy 
Psychosocial Therapies 




Individual Psychotherapies 


Characteristics of a Crisis 


Relaxation Therapy 


Phases in the Development of a Crisis 


Assertiveness Training 


Types of Crises 


Cognitive Therapy 


Class 1: Dispositional Crises 


Summary and Key Points 


Class 2: Crises of Anticipated 

Life Transitions 183 

Class 3: Crises Resulting 

From Traumatic Stress 183 

Class 4: Maturational/Developmental 

Crises 183 

Class 5: Crises Reflecting 

Psychopathology 183 

Class 6: Psychiatric Emergencies 184 

Crisis Intervention 184 



Chapter 12: Delirium, Dementia, 

and Amnestic Disorders 



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Clinical Findings and Course 


Etiological Implications 




Clinical Findings, Epidemiology, 

and Course 


Etiological Implications 


Amnestic Disorders 


Etiological Implications 


Application of the Nursing Process 




Nursing Diagnosis/Outcome 





Concept Care Mapping 


Client/Family Education 




Medical Treatment Modalities 






Summary and Key Points 


Substance-Related Disorders 




Substance-Use Disorders 


Substance Abuse 


Substance Dependence 


Substance-Induced Disorders 


Substance Intoxication 


Substance Withdrawal 


Classes of Psychoactive Substances 


Etiological Implications 


Biological Factors 


Psychological Factors 


Sociocultural Factors 


The Dynamics of Substance-Related 



Alcohol Abuse and Dependence 


Alcohol Intoxication 


Alcohol Withdrawal 


Sedative, Hypnotic, or Anxiolytic 

Abuse and Dependence 276 
Sedative, Hypnotic, or Anxiolytic 

Intoxication 278 
Sedative, Hypnotic, or Anxiolytic 

Withdrawal 279 
CNS Stimulant Abuse and 

Dependence 279 

CNS Stimulant Intoxication 282 

CNS Stimulant Withdrawal 282 

Inhalant Abuse and Dependence 283 

Inhalant Intoxication 283 

Opioid Abuse and Dependence 284 

Opioid Intoxication 


Opioid Withdrawal 


Hallucinogen Abuse and Dependence 


Hallucinogen Intoxication 


Cannabis Abuse and Dependence 


Cannabis Intoxication 


Application of the Nursing Process 




Diagnosis/Outcome Identification 






Treatment Modalities for Substance- 

Related Disorders 


Alcoholics Anonymous 






Group Therapy 


Psychopharmacology for Substance 

Intoxication and Substance 



Summary and Key Points 


Chapter 14: Schizophrenia and Other 

Psychotic Disorders 316 

Introduction 317 

Nature of the Disorder 318 

Phase I. The Premorbid Phase 318 

Phase II. The Prodromal Phase 318 

Phase III. Schizophrenia 319 

Phase IV. Residual Phase 319 

Prognosis 319 

Etiological Implications 319 

Biological Influences 320 

Psychological Influences 322 

Environmental Influences 323 

Theoretical Integration 323 

Types of Schizophrenia and 

Other Psychotic Disorders 323 

Disorganized Schizophrenia 323 

Catatonic Schizophrenia 323 

Paranoid Schizophrenia 324 

Undifferentiated Schizophrenia 324 

Residual Schizophrenia 324 

Schizoaffective Disorder 324 

Brief Psychotic Disorder 324 

Schizophreniform Disorder 324 

Delusional Disorder 325 

Shared Psychotic Disorder 325 
Psychotic Disorder Due to a General 

Medical Condition 325 
Substance-Induced Psychotic 

Disorder 325 

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Application of the Nursing Process 

Background Assessment Data 
Diagnosis/Outcome Identification 

Treatment Modalities 
for Schizophrenia and Other 
Psychotic Disorders 
Psychological Treatments 
Social Treatment 
Organic Treatment 

Summary and Key Points 

Chapter 15: Mood Disorders — Depression 

Historical Perspective 

Age and Gender 

Social Class 

Race and Culture 

Marital Status 

Types of Depressive Disorders 

Major Depressive Disorder 

Dysthymic Disorder 

Premenstrual Dysphoric Disorder 

Other Depressive Disorders 
Etiological Implications 

Biological Theories 

Psychosocial Theories 
Developmental Implications 




Postpartum Depression 
Application of the Nursing Process 

Background Assessment Data 

Diagnosis/Outcome Identification 


Evaluation of Care for the 
Depressed Client 
Treatment Modalities for Depression 

Individual Psychotherapy 

Group Therapy 

Family Therapy 

Cognitive Therapy 

Electroconvulsive Therapy 

Transcranial Magnetic 

Light Therapy 



The Suicidal Client 



Epidemiological Factors 



Application of the Nursing Process 


With the Suicidal Client 





Diagnosis/Outcome Identification 








Summary and Key Points 



Chapter 16: Mood Disorders — Bipolar 






Historical Perspective 






Types of Bipolar Disorders 



Bipolar I Disorder 



Bipolar II Disorder 



Cyclothymic Disorder 



Other Bipolar Disorders 



Etiological Implications 



Biological Theories 



Psychosocial Theories 



Developmental Implications 



Childhood and Adolescence 



Application of the Nursing 


Process to Bipolar Disorder (Mania) 



Background Assessment Data 



Diagnosis/Outcome Identification 






Evaluation of Care for the Manic 





Treatment Modalities for Bipolar 


Disorder (Mania) 



Individual Psychotherapy 



Group Therapy 



Family Therapy 



Cognitive Therapy 



Electroconvulsive Therapy 
Psychopharmacology With 



Mood-Stabilizing Agents 



Summary and Key Points 



Chapter 17: Anxiety Disorders 






Historical Aspects 



Epidemiological Statistics 


How Much Is Too Much? 



Application of the Nursing Process 



Panic Disorder 



Generalized Anxiety Disorder 




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Obsessive-Compulsive Disorder 


Post-Traumatic Stress Disorder 


Anxiety Disorder Due to a 

General Medical Condition 


Substance-Induced Anxiety Disorder 


Treatment Modalities 


Individual Psychotherapy 


Cognitive Therapy 


Behavior Therapy 


Group/Family Therapy 




Summary and Key Points 


Chapter 18: Somatoform and Dissociative 

Disorders 474 

Introduction 475 

Historical Aspects 475 

Epidemiological Statistics 476 

Application of the Nursing Process 477 

Background Assessment Data: 

Types of Somatoform Disorders 477 
Etiological Implications for 

Somatoform Disorders 481 
Background Assessment Data: 

Types of Dissociative Disorders 481 
Etiological Implications for 

Dissociative Disorders 484 

Diagnosis/Outcome Identification 485 

Planning/Implementation 486 

Concept Care Mapping 486 

Evaluation 495 

Treatment Modalities 495 

Somatoform Disorders 495 

Dissociative Amnesia 498 

Dissociative Fugue 498 

Dissociative Identity Disorder 499 

Depersonalization Disorder 499 

Summary and Key Points 501 

Chapter 19: Issues Related to 

Human Sexuality 506 



Development of Human Sexuality 


Birth Through Age 12 






Sexual Disorders 




Sexual Dysfunctions 


Application of the Nursing 

Process to Sexual Disorders 


Treatment Modalities for 

Sexual Dysfunctions 


Variations in Sexual Orientation 








Sexually Transmitted Diseases 


Summary and Key Points 


Eating Disorders 




Epidemiological Factors 


Application of the Nursing Process 


Background Assessment Data 

(Anorexia Nervosa) 


Background Assessment Data 

(Bulimia Nervosa) 


Background Assessment Data 



Diagnosis/Outcome Identification 




Client/Family Education 




Treatment Modalities 


Behavior Modification 


Individual Therapy 


Family Therapy 




Summary and Key Points 


Chapter 21: Personality Disorders 564 

Introduction 565 

Historical Aspects 566 

Types of Personality Disorders 567 

Paranoid Personality Disorder 567 

Schizoid Personality Disorder 568 

Schizotypal Personality Disorder 568 

Antisocial Personality Disorder 569 

Borderline Personality Disorder 569 

Histrionic Personality Disorder 569 

Narcissistic Personality Disorder 570 

Avoidant Personality Disorder 571 

Dependent Personality Disorder 571 
Obsessive-Compulsive Personality 

Disorder 572 
Passive-Aggressive Personality 

Disorder 573 

Application of the Nursing Process 573 
Borderline Personality Disorder 

(Background Assessment Data) 573 

Diagnosis/Outcome Identification 576 

Planning/Implementation 577 

Evaluation 577 
Antisocial Personality Disorder 

(Background Assessment Data) 581 

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Diagnosis/Outcome Identification 584 

Planning/Implementation 584 

Etiological Implications 
Application of the Nursing Process 




to Tourette's Disorder 


Treatment Modalities 


Separation Anxiety Disorder 


Interpersonal Psychotherapy 


Clinical Findings, Epidemiology, 

Psychoanalytical Psychotherapy 


and Course 


Milieu or Group Therapy 


Etiological Implications 


Cognitive/Behavioral Therapy 


Application of the Nursing Process 

Dialectical Behavior Therapy 


to Separation Anxiety Disorder 




General Therapeutic Approaches 


Summary and Key Points 


Behavior Therapy 


Family Therapy 



Group Therapy 






Summary and Key Points 
Chapter 23: Victims of Abuse or Neglect 



Chapter 22: Children and Adolescents 






Etiological Implications 


Mental Retardation 


Biological Theories 


Etiological Implications 


Psychological Theories 


Application of the Nursing Process 

Sociocultural Theories 


to Mental Retardation 


Application of the Nursing Process 


Autistic Disorder 


Background Assessment Data 


Clinical Findings 


Diagnosis/Outcome Identification 


Epidemiology and Course 




Etiological Implications 




Application of the Nursing Process 

Treatment Modalities 


to Autistic Disorder 


Crisis Intervention 



The Safe House or Shelter 


Intervention for Autistic Disorder 


Family Therapy 


Attention Deficit-Hyperactivity 

Clinical Findings, Epidemiology, 


Summary and Key Points 


Chapter 24: The Aging Individual 


and Course 




Etiological Implications 


How Old Is Old? 


Application of the Nursing Process 

Epidemiological Statistics 


to ADHD 


The Population 


Psychopharmacological Intervention 

Marital Status 


for ADHD 


Living Arrangements 


Conduct Disorder 


Economic Status 


Etiological Implications 




Application of the Nursing Process 

Health Status 


to Conduct Disorder 


Theories of Aging 


Oppositional Defiant Disorder 


Biological Theories 


Clinical Findings, Epidemiology, 

Psychosocial Theories 


and Course 


The Normal Aging Process 


Etiological Implications 


Biological Aspects of Aging 


Application of the Nursing Process 

Psychological Aspects of Aging 


to ODD 


Sociocultural Aspects of Aging 


Tourette's Disorder 


Sexual Aspects of Aging 


Clinical Findings, Epidemiology, 

and Course 


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Special Concerns of the Elderly 

Population 681 

Retirement 681 

Long-Term Care 683 

Elder Abuse 684 

Suicide 686 

Application of the Nursing Process 687 

Assessment 687 

Diagnosis/Outcome Identification 687 

Planning/Implementation 689 

Evaluation 689 

Summary and Key Points 695 

Chapter 25: Community Mental 

Health Nursing 702 

Chapter 26: 



The Changing Focus of Care 


The Public Health Model 


The Community as Client 


Appendix A: 

Primary Prevention 


Secondary Prevention 


Tertiary Prevention 


Appendix B: 

Summary and Key Points 


The Bereaved Individual 


Appendix C: 



Theoretical Perspectives on Loss 

Appendix D: 

and Bereavement 


Stages of Grief 


Appendix E: 

Length of the Grief Process 


Appendix F: 

Anticipatory Grief 


Maladaptive Responses to Loss 


Delayed or Inhibited Grief 


Distorted (Exaggerated) Grief 



Chronic or Prolonged Grieving 


Normal Versus Maladaptive Grieving 


Application of the Nursing Process 

Background Assessment Data: 

Concepts of Death — 

Developmental Issues 
Background Assessment Data: 

Concepts of Death — Cultural 

Nursing Diagnosis/Outcome 

Additional Assistance 

Advance Directives 
Summary and Key Points 

DSM-IV-TR Classification: 
Axes I and II Categories and 

NANDA Nursing Diagnoses: 
Taxonomy II 

Assigning Nursing Diagnoses 
to Client Behaviors 

Mental Status Assessment 


Answers to Review Questions 









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Essentials of 

Mental Health 




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Unit One 


to Psychiatric/ 

Mental Health 


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H A P T E R 

Mental Health 
and Mental Illness 












anticipatory grief 

bereavement overload 

Diagnostic and 

Statistical Manual 
of Men tal Disorders, 
Fourth Edition, Text 
Revision (DSM-IV-TR) 

ego defense mechanisms 
fight or flight syndrome 


anxiety grief 


After reading this chapter, the student will be able to: 


Define mental health and mental illness. 
Discuss cultural elements that influence 
attitudes toward mental health and 
mental illness. 
Identify physiological responses to stress. 

4. Discuss the concepts of anxiety and grief 
as psychological responses to stress. 

5. Describe the DSM-IV-TR multiaxial 
evaluation system for classification of 
mental disorders. 

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Please read the chapter and answer the following questions. 

1. Explain the concepts of incomprehensibility 
and cultural relativity. 

2. Describe some symptoms of panic anxiety. 

3. Jane was involved in an automobile 
accident in which both her parents were 
killed. When you ask her about it, she 

says she has no memory of the accident. 
What ego defense mechanism is she 
4. In what stage of the grieving process is 
the individual with delayed or inhibited 
grief fixed? 


The concepts of mental health and mental illness are 
culturally defined. Some cultures are quite liberal in the 
range of behaviors that are considered acceptable, where- 
as others have very little tolerance for behaviors that de- 
viate from the cultural norms. A study of the history of 
psychiatric care reveals some shocking truths about past 
treatment of mentally ill individuals. Many were kept in 
control by means that were cruel and inhumane. 

Primitive beliefs regarding mental disturbances took 
several views. Some thought that an individual with 
mental illness had been dispossessed of his or her soul 
and that the only way wellness could be achieved was 
if the soul returned. Others believed that evil spirits or 
supernatural or magical powers had entered the body. 
The "cure" for these individuals involved a ritualistic 
exorcism, which often consisted of brutal beatings, 
starvation, or other torturous means, to purge the body 
of these unwanted forces. Still others considered that 
the mentally ill individual may have broken a taboo or 
sinned against another individual or God, for which 
ritualistic purification was required or various types of 
retribution were demanded. The correlation of mental 
illness to demonology or witchcraft led to some men- 
tally ill individuals being burned at the stake. 

This chapter defines mental health and mental illness 
and describes physical and psychological responses 
to stress. The Diagnostic and Statistical Manual of 
Mental Disorders, Fourth Edition, Text Revision 
(DSM-IV-TR), multiaxial evaluation system is also 


A number of theorists have attempted to define the 
concept of mental health. Many of these concepts deal 

with various aspects of individual functioning. Maslow 
(1970) emphasized an individual's motivation in the 
continuous quest for self-actualization. He identified a 
"hierarchy of needs," the lower needs requiring fulfill- 
ment before those at higher levels can be achieved, with 
self-actualization being fulfillment of one's highest po- 
tential. An individual's position within the hierarchy 
may fluctuate based on life circumstances. For exam- 
ple, an individual facing major surgery who has been 
working on tasks to achieve self-actualization may be- 
come preoccupied, if only temporarily, with the need 
for physiological safety. A representation of this needs 
hierarchy is presented in Figure 1-1. 

(The individual 
possesses a 
feeling of self- 
fulfillment and 
the realization 
of his or her 
highest potential.) 

(The individual seeks self-respect 
and respect from others, works to 
achieve success and recognition in 
work, and desires prestige from 

(Needs are for giving and receiving of 
affection, companionship, satisfactory 
interpersonal relationships, and 
identification with a group.) 


(Needs at this level are for avoiding harm, maintaining 
comfort, order, structure, physical safety, freedom from 
fear, and protection.) 


(Basic fundamental needs include food, water, air, sleep, exercise, 

elimination, shelter, and sexual expression.) 

FIGURE 1—1 Maslow's hierarchy of needs. 

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Maslow described self-actualization as the state of 
being "psychologically healthy, fully human, highly 
evolved, and fully mature." He believed that healthy, 
or self-actualized, individuals possessed the following 

• An appropriate perception of reality 

• The ability to accept oneself, others, and human 

• The ability to manifest spontaneity 

• The capacity for focusing concentration on problem- 

• A need for detachment and desire for privacy 

• Independence, autonomy, and a resistance to encul- 

• An intensity of emotional reaction 

• A frequency of "peak" experiences that validate the 
worthwhileness, richness, and beauty of life 

• An identification with humankind 

• The ability to achieve satisfactory interpersonal 

• A democratic character structure and strong sense 
of ethics 

• Creativeness 

• A degree of nonconformance 

The American Psychiatric Association (APA) (2003) 
defines mental health as "a state of being that is rela- 
tive rather than absolute. The successful performance 
of mental functions shown by productive activities, 
fulfilling relationships with other people, and the abil- 
ity to adapt to change and to cope with adversity." 

Townsend (2009) defines mental health as "the suc- 
cessful adaptation to stressors from the internal or ex- 
ternal environment, evidenced by thoughts, feelings, 
and behaviors that are age-appropriate and congruent 
with local and cultural norms" (p. 14). 

This definition of mental health will be used for pur- 
poses of this text. 


A universal concept of mental illness is difficult to de- 
fine because of the cultural factors that influence such a 
concept. However, certain elements are associated with 
individuals' perceptions of mental illness, regardless of 
cultural origin. Horwitz (2002) identifies two of these 
elements as incomprehensibility and cultural relativity. 

Incomprehensibility relates to the inability of the gen- 
eral population to understand the motivation behind 
the behavior. When observers are unable to find mean- 
ing or comprehensibility in behavior, they are likely to 
label that behavior as mental illness. Horwitz states, 

"Observers attribute labels of mental illness when the 
rules, conventions, and understandings they use to 
interpret behavior fail to find any intelligible motiva- 
tion behind an action." 

The element of cultural relativity considers that these 
rules, conventions, and understandings are conceived 
within an individual's own particular culture. Behavior 
is categorized as "normal" or "abnormal" according to 
one's cultural or societal norms. Therefore, a behavior 
that is recognized as evidence of mental illness in one 
society may be viewed as normal in another society and 
vice versa. Horwitz identified a number of cultural as- 
pects of mental illness, which are presented in Box 1-1. 

In the DSM-IV-TR (APA, 2000), the APA defines 
mental illness or a mental disorder as "a clinically signifi- 
cant behavioral or psychological syndrome or pattern 

Box 1-1 Cultural Aspects of Mental Illness 

1 . It is usually members of the lay community rather than 
a psychiatric professional who initially recognize that an 
individual's behavior deviates from the social norms. 

2. People who are related to an individual or who are 
of the same cultural or social group are less likely to 
label that individual's behavior as mental illness than 
someone who is relationally or culturally distant. Fam- 
ily members (or people of the same cultural or social 
group) try to "normalize" the behavior and try to find 
an explanation for it. 

3 . Psychiatrists see a person with mental illness most of- 
ten when the family members can no longer deny the 
illness and often when the behavior is at its worst. The 
local or cultural norms define pathological behavior. 

4. Individuals in the lowest socioeconomic class usually 
display the highest amount of mental illness symp- 
toms. However, they tend to tolerate a wider range of 
behaviors that deviate from societal norms and are less 
likely to consider these behaviors as indicative of men- 
tal illness. Mental illness labels are most often applied 
by psychiatric professionals. 

5. The higher the social class, the greater the recogni- 
tion of mental illness behaviors (as defined by societal 
norms). Members of the higher social classes are likely 
to be self-labeled or labeled by family members or 
friends. Psychiatric assistance is sought soon after the 
first signs of emotional disturbance. 

6. The more highly educated the person, the greater the 
recognition of mental illness behaviors. However, even 
more relevant than amount of education is type of edu- 
cation. Individuals in the more humanistic types of pro- 
fessions (e.g., lawyers, social workers, artists, teachers, 
nurses) are more likely to seek psychiatric assistance 
than other professionals such as business executives, 
computer specialists, accountants, and engineers. 

7. In terms of religion, Jewish people are more likely to 
seek psychiatric assistance than are people who are 
Catholic or Protestant. 


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^ Box 1-1 

Cultural Aspects of Mental 
Illness— cont'd 

8. Women are more likely than men to recognize the 
symptoms of mental illness and seek assistance. 

9. The greater the cultural distance from the mainstream 
of society (i.e., the fewer the ties with conventional soci- 
ety), the greater the likelihood of a negative response by 
society to mental illness. For example, immigrants have 
a greater distance from the mainstream than the native 
born, ethnic minorities greater than the dominant cul- 
ture, and "bohemians" more than bourgeoisie. They are 
more likely to be subjected to coercive treatment, and in- 
voluntary psychiatric commitments are more common. 

Source: Adapted from Horwitz (2002). 

that occurs in an individual and that is associated 
with present distress (e.g., a painful symptom) or dis- 
ability (i.e., impairment in one or more important ar- 
eas of functioning), or with a significantly increased 
risk of suffering death, pain, disability, or an important 
loss of freedom . . . and is not merely an expectable . . . 
response to a particular event" (p. xxxi). 

Townsend (2009) defines mental illness as "maladap- 
tive responses to stressors from the internal or exter- 
nal environment, evidenced by thoughts, feelings, and 
behaviors that are incongruent with the local and cul- 
tural norms, and interfere with the individual's social, 
occupational, and/or physical functioning" (p. 15). 

This definition of mental illness will be used for 
purposes of this text. 


Physical Responses 

In 1956, Hans Selye published the results of his research 
concerning the physiological response of a biological 
system to a change imposed on it. After the initial pub- 
lication of his findings, he revised his definition of stress 
to "the state manifested by a specific syndrome which 
consists of all the nonspecifically-induced changes 
within a biologic system" (Selye, 1976, p. 64). This syn- 
drome of symptoms has come to be known as the fight 
or flight syndrome. Selye called this general reaction 
of the body to stress the general adaptation syndrome. He 
described the reaction in three distinct stages: 

1 . Alarm reaction stage: During this stage, the phys- 
iological responses of the fight or flight syndrome 
are initiated. 

2. Stage of resistance: The individual uses the physi- 
ological responses of the first stage as a defense in 

the attempt to adapt to the stressor. If adaptation 
occurs, the third stage is prevented or delayed. 
Physiological symptoms may disappear. 
3 . Stage of exhaustion: This stage occurs when there 
is a prolonged exposure to the stressor to which the 
body has become adjusted. The adaptive energy is 
depleted, and the individual can no longer draw from 
the resources for adaptation described in the first two 
stages. Diseases of adaptation (e.g., headaches, mental 
disorders, coronary artery disease, ulcers, colitis) may 
occur. Without intervention for reversal, exhaustion 
and even death ensues (Selye, 1956, 1974). 

Biological responses associated with the fight or 
flight syndrome include the following: 

• The immediate response: The hypothalamus stim- 
ulates the sympathetic nervous system, which results 
in the following physical effects: 

The adrenal medulla releases norepinephrine 
and epinephrine into the bloodstream. 
The pupils of the eye dilate. 
Secretion from the lacrimal (tear) glands is in- 

1 In the lungs, the bronchioles dilate and the respi- 
ration rate is increased. 

The force of cardiac contraction increases, as does 
cardiac output, heart rate, and blood pressure. 
Gastrointestinal motility and secretions decrease, 
and sphincter contracts. 

* In the liver, there is increased glycogenolysis 
and gluconeogenesis and decreased glycogen 

The bladder muscle contracts and the sphincter 
relaxes; there is increased ureter motility. 
Secretion from the sweat glands is increased. 
Lipolysis occurs in the fat cells. 

• The sustained response: When the stress re- 
sponse is not relieved immediately and the indi- 
vidual remains under stress for a long period of 
time, the hypothalamus stimulates the pituitary 
gland to release hormones that produce the fol- 
lowing effects: 

Adrenocorticotropic hormone (ACTH) stimulates 
the adrenal cortex to release glucocorticoids and 
mineralocorticoids, resulting in increased gluco- 
neogenesis and retention of sodium and water and 
decreased immune and inflammatory responses. 
Vasopressin (antidiuretic hormone) increases 
fluid retention and also increases blood pressure 
through constriction of blood vessels. 
Growth hormone has a direct effect on protein, 
carbohydrate, and lipid metabolism, resulting in 
increased serum glucose and free fatty acids. 

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Thyrotropic hormone stimulates the thyroid 
gland to increase the basal metabolic rate. 
Gonadotropins cause a decrease in secretion of 
sex hormones, resulting in decreased libido and 

This fight or flight response undoubtedly served our 
ancestors well. Those Homo sapiens who had to face the 
giant grizzly bear or the saber- toothed tiger as a facet of 
their struggle for survival must have used these adaptive 
resources to their advantage. The response was elicited 
in emergencies, used in the preservation of life, and fol- 
lowed by restoration of the compensatory mechanisms 
to the preemergent condition (homeostasis). 

Selye performed his extensive research in a con- 
trolled setting with laboratory animals as subjects. He 
elicited physiological responses with physical stimuli, 
such as exposure to heat or extreme cold, electric shock, 
injection of toxic agents, restraint, and surgical injury. 
Since the publication of Selye 's original research, it has 
become apparent that the fight or flight syndrome oc- 
curs in response to psychological or emotional stimuli, 
just as it does to physical stimuli. The psychological or 
emotional stressors are often not resolved as rapidly 
as some physical stressors; therefore, the body may be 
depleted of its adaptive energy more readily than it is 
from physical stressors. The fight or flight response 
may be inappropriate or even dangerous to the lifestyle 
of today, wherein stress has been described as a psycho- 
social state that is pervasive, chronic, and relentless. It 
is this chronic response that maintains the body in the 
aroused condition for extended periods that promotes 
susceptibility to diseases of adaptation. 

Psychological Responses 

Anxiety and grief have been described as two major, 
primary psychological response patterns to stress. A 
variety of thoughts, feelings, and behaviors are associ- 
ated with each of these response patterns. Adaptation 
is determined by the degree to which the thoughts, 
feelings, and behaviors interfere with an individual's 



A diffuse apprehension that is vague in nature and 
is associated with feelings of uncertainty and help- 


Feelings of anxiety are so common in our society that 
they are almost considered universal. Anxiety arises 
from the chaos and confusion that exists in the world 
today. Fears of the unknown and conditions of ambi- 
guity offer a perfect breeding ground for anxiety to 
take root and grow. Low levels of anxiety are adaptive 
and can provide the motivation required for survival. 
Anxiety becomes problematic when the individual is 
unable to prevent the anxiety from escalating to a level 
that interferes with the ability to meet basic needs. 

Peplau (1963) described four levels of anxiety: mild, 
moderate, severe, and panic. Nurses must be able to rec- 
ognize the symptoms associated with each level to plan 
for appropriate intervention with anxious individuals. 

• Mild anxiety: This level of anxiety is seldom a 
problem for the individual. It is associated with the 
tension experienced in response to the events of 
day-to-day living. Mild anxiety prepares people for 
action. It sharpens the senses, increases motivation 
for productivity, increases the perceptual field, and 
results in a heightened awareness of the environ- 
ment. Learning is enhanced, and the individual is 
able to function at his or her optimal level. 

• Moderate anxiety: As the level of anxiety increases, 
the extent of the perceptual field diminishes. The 
moderately anxious individual is less alert to events 
occurring within the environment. The individual's 
attention span and ability to concentrate decrease, 
although he or she may still attend to needs with 
direction. Assistance with problem-solving may be 
required. Increased muscular tension and restless- 
ness are evident. 

• Severe anxiety: The perceptual field of the severely 
anxious individual is so greatly diminished that con- 
centration centers on one particular detail only or 
on many extraneous details. Attention span is ex- 
tremely limited, and the individual has much dif- 
ficulty completing even the simplest task. Physical 
symptoms (e.g., headaches, palpitations, insomnia) 
and emotional symptoms (e.g., confusion, dread, 
horror) may be evident. Discomfort is experienced 
to the degree that virtually all overt behavior is 
aimed at relieving the anxiety. 

• Panic anxiety: In this most intense state of anxiety, the 
individual is unable to focus on even one detail within 
the environment. Misperceptions are common, and a 
loss of contact with reality may occur. The individual 
may experience hallucinations or delusions. Behavior 
may be characterized by wild and desperate actions 
or extreme withdrawal. Human functioning and com- 
munication with others are ineffective. Panic anxiety 

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is associated with a feeling of terror, and individuals 
may be convinced that they have a life-threatening ill- 
ness or fear that they are "going crazy," are losing con- 
trol, or are emotionally weak (APA, 2000). Prolonged 
panic anxiety can lead to physical and emotional ex- 
haustion and can be life threatening. 

A variety of behavioral adaptation responses occur 
at each level of anxiety. Figure 1-2 depicts these be- 
havioral responses on a continuum of anxiety ranging 
from mild to panic. 

Mild Anxiety 

At the mild level, individuals use any of a number of 
coping behaviors that satisfy their needs for comfort. 
Menninger (1963) described the following types of 
coping mechanisms that individuals use to relieve anx- 
iety in stressful situations: 

• Sleeping 

• Eating 

• Physical exercise 

• Smoking 

• Crying 

• Yawning 

• Drinking 

• Daydreaming 

• Laughing 

• Cursing 

• Pacing 

• Foot swinging 

• Fidgeting 

• Nail biting 

• Finger tapping 

• Talking to someone with whom one feels comfortable 

Undoubtedly, there are many more responses too 
numerous to mention here, considering that each in- 
dividual develops his or her own unique ways to relieve 
anxiety at the mild level. Some of these behaviors are 
much more adaptive than others. 

Mild to Moderate Anxiety 

Sigmund Freud (1961) identified the ego as the reality 
component of the personality that governs problem- 
solving and rational thinking. As the level of anxiety 


Coping Ego 

mechanisms defense 







FIGURE 1-2 Adaptation responses on a continuum of anxiety. 

increases, the strength of the ego is tested, and energy 
is mobilized to confront the threat. Anna Freud (1953) 
identified a number of defense mechanisms employed 
by the ego in the face of threat to biological or psy- 
chological integrity (Table 1-1). Some of these ego 
defense mechanisms are more adaptive than others, 
but all are used either consciously or unconsciously 
as protective devices for the ego in an effort to relieve 
mild to moderate anxiety. They become maladaptive 
when an individual uses them to such a degree that 
there is interference with the ability to deal with real- 
ity, with interpersonal relations, or with occupational 

Moderate to Severe Anxiety 

Anxiety at the moderate to severe level that remains 
unresolved over an extended period can contribute 
to a number of physiological disorders. The DSM- 
IV-TR (APA, 2000) describes these disorders as "the 
presence of one or more specific psychological or be- 
havioral factors that adversely affect a general medical 
condition." The psychological factors may exacerbate 
symptoms of, delay recovery from, or interfere with 
treatment of the medical condition. The condition 
may be initiated or exacerbated by an environmen- 
tal situation that the individual perceives as stressful. 
Measurable pathophysiology can be demonstrated. 
The DSM-IV-TR states: 

Psychological and behavioral factors may affect the 
course of almost every major category of disease, 
including cardiovascular conditions, dermatological 
conditions, endocrinological conditions, gastrointes- 
tinal conditions, neoplastic conditions, neurological 
conditions, pulmonary conditions, renal conditions, 
and rheumatological conditions. (APA, 2000, p. 732) 

Severe Anxiety 

Extended periods of repressed severe anxiety can re- 
sult in psychoneurotic patterns of behaving. Neuro- 
sis is no longer a separate category of disorders in 
the DSM-IV-TR (APA, 2000). However, the term 
is still used in the literature to further describe the 
symptomatology of certain disorders. Neuroses are 
psychiatric disturbances, characterized by excessive 
anxiety that is expressed directly or altered through 
defense mechanisms. It appears as a symptom, such 
as an obsession, a compulsion, a phobia, or a sexual 
dysfunction (Sadock & Sadock, 2007). The following 
are common characteristics of people with neuroses: 

• They are aware that they are experiencing distress. 

• They are aware that their behaviors are maladaptive. 

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Table 1 

Ego Defense Mechanisms 

Defense Mechanism 


Covering up a real or perceived 
weakness by emphasizing 
a trait one considers more 


A physically handicapped boy 
is unable to participate in 
football, so he compensates 
by becoming a great scholar. 

Defense Mechanism 


Attempting to make excuses or 
formulate logical reasons to 
justify unacceptable feelings 
or behaviors 


John tells the rehab nurse, "I 
drink because it's the only 
way I can deal with my bad 
marriage and my worse job.' 


Reaction Formation 

Refusing to acknowledge the 

A woman drinks alcohol every 

Preventing unacceptable 

Jane hates nursing. She at- 

existence of a real situation 

day and cannot stop, failing 

or undesirable thoughts 

tended nursing school to 

or the feelings associated 

to acknowledge that she has 

or behaviors from being 

please her parents. During 

with it 

a problem. 

expressed by exaggerating 

career day, she speaks to 

opposite thoughts or types 

prospective students about 

of behaviors 

the excellence of nursing as 
a career. 



The transfer of feelings from 

A client is angry at his doctor, 

Responding to stress by re- 

When 2 -year-old Jay is hospi- 

one target to another that is 

does not express it, but be- 

treating to an earlier level of 

talized for tonsillitis he will 

considered less threatening 

comes verbally abusive with 

development and the com- 

drink only from a bottle, 

or that is neutral 

the nurse. 

fort measures associated with 

although his mother states 

that level of functioning 

he has been drinking from a 
cup for 6 months. 



An attempt to increase self- 

A teenaged boy who required 

Involuntarily blocking unpleas- 

An accident victim can re- 

worth by acquiring certain 

lengthy rehabilitation after 

ant feelings and experiences 

member nothing about the 

attributes and characteristics 

an accident decides to be- 

from one's awareness 


of an individual one admires 

come a physical therapist as 
a result of his experiences. 



An attempt to avoid expressing 

Susan's husband is being 

Rechanneling of drives or 

A mother whose son was killed 

actual emotions associated 

transferred with his job to 

impulses that are personally 

by a drunk driver channels 

with a stressful situation by 

a city far away from her 

or socially unacceptable into 

her anger and energy into 

using the intellectual proc- 

parents. She hides anxiety by 

activities that are construc- 

being the president of the 

esses of logic, reasoning, and 

explaining to her parents the 


local chapter of Mothers 


advantages associated with 
the move. 

Against Drunk Drivers. 



Integrating the beliefs and 

Children integrate their par- 

The voluntary blocking of un- 

Scarlett O'Hara says, "I don't 

values of another individual 

ents' value system into the 

pleasant feelings and experi- 

want to think about that 

into one's own ego structure 

process of conscience forma- 

ences from one's awareness 

now. I'll think about that 

tion. A child says to friend, 


"Don't cheat. It's wrong." 



Separating a thought or 

Without showing any emotion, 

Symbolically negating or can- 

Joe is nervous about his new 

memory from the feeling 

a young woman describes 

celing out an experience that 

job and yells at his wife. On 

tone or emotion associated 

being attacked and raped. 

one finds intolerable 

his way home, he stops and 

with it 

buys her some flowers. 


Attributing feelings or im- 

Sue feels a strong sexual at- 

pulses unacceptable to one's 

traction to her track coach 

self to another person 

and tells her friend, "He's 
coming on to me!" 

2338_Ch01_001-015.indd 9 

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• They are unaware of any possible psychological 
causes of the distress. 

• They feel helpless to change their situation. 

• They experience no loss of contact with reality. 

The following disorders are examples of psychoneu- 
rotic responses to severe anxiety as they appear in the 

• Anxiety disorders: Disorders in which the charac- 
teristic features are symptoms of anxiety and avoid- 
ance behavior (e.g., phobias, obsessive-compulsive 
disorder, panic disorder, generalized anxiety disor- 
der, post- traumatic stress disorder). 

• Somatoform disorders: Disorders in which the 
characteristic features are physical symptoms for 
which there is no demonstrable organic pathol- 
ogy. Psychological factors are judged to play a sig- 
nificant role in the onset, severity, exacerbation, or 
maintenance of the symptoms (e.g., hypochondria- 
sis, conversion disorder, somatization disorder, pain 

• Dissociative disorders: Disorders in which 
the characteristic feature is a disruption in the 
usually integrated functions of consciousness, 
memory, identity, or perception of the environ- 
ment (e.g., dissociative amnesia, dissociative fugue, 
dissociative identity disorder, depersonalization 

Panic Anxiety 

At this extreme level of anxiety, an individual is not 
capable of processing what is happening in the envi- 
ronment and may lose contact with reality. Psychosis 
is defined as a loss of ego boundaries or a gross im- 
pairment in reality testing (APA, 2000). Psychoses are 
serious psychiatric disturbances characterized by the 
presence of delusions or hallucinations and the impair- 
ment of interpersonal functioning and relationship to 
the external world. The following are common charac- 
teristics of people with psychoses: 

• They exhibit minimal distress (emotional tone is 
flat, bland, or inappropriate). 

• They are unaware that their behavior is maladaptive. 

• They are unaware of any psychological problems. 

• They are exhibiting a flight from reality into a less 
stressful world or into one in which they are at- 
tempting to adapt. 

Examples of psychotic responses to anxiety in- 
clude the schizophrenic, schizoaffective, and delu- 
sional disorders. 



A subjective state of emotional, physical, and so- 
cial responses to the loss of a valued entity. 


Most individuals experience intense emotional anguish 
in response to a significant personal loss. A loss is any- 
thing that is perceived as such by the individual. Losses 
may be real, in which case it can be substantiated by 
others (e.g., death of a loved one, loss of personal pos- 
sessions), or they may be perceived by the individual 
alone and unable to be shared or identified by others 
(e.g., loss of the feeling of femininity following a mas- 
tectomy). Any situation that creates change for an in- 
dividual can be identified as a loss. Failure (either real 
or perceived) can also be viewed as a loss. 

The loss, or anticipated loss, of anything of value to 
an individual can trigger the grief response. This period 
of characteristic emotions and behaviors is called mourn- 
ing. The "normal" mourning process is adaptive and is 
characterized by feelings of sadness, guilt, anger, help- 
lessness, hopelessness, and despair. Indeed, an absence of 
mourning after a loss may be considered maladaptive. 

Stages of Grief 

Kiibler-Ross (1969), in extensive research with termi- 
nally ill patients, identified five stages of feelings and 
behaviors that individuals experience in response to a 
real, perceived, or anticipated loss: 

• Stage 1 — Denial: This is a stage of shock and dis- 
belief. The response may be one of "No, it can't be 
true!" The reality of the loss is not acknowledged. 
Denial is a protective mechanism that allows the 
individual to cope within an immediate time frame 
while organizing more effective defense strategies. 

• Stage 2 — Anger: "Why me?" and "It's not fair!" are 
comments often expressed during the anger stage. 
Envy and resentment toward individuals not affect- 
ed by the loss are common. Anger may be directed 
at the self or displaced on loved ones, caregivers, 
and even God. There may be a preoccupation with 
an idealized image of the lost entity. 

• Stage 3 — Bargaining: "If God will help me through 
this, I promise I will go to church every Sunday and 
volunteer my time to help others." During this stage, 

2338_Ch01_001-015.indd 10 

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which is usually not visible or evident to others, a 
"bargain" is made with God in an attempt to reverse 
or postpone the loss. Sometimes the promise is asso- 
ciated with feelings of guilt for not having performed 
satisfactorily, appropriately, or sufficiently 

• Stage 4 — Depression: During this stage, the full im- 
pact of the loss is experienced. The sense of loss is in- 
tense, and feelings of sadness and depression prevail. 
This is a time of quiet desperation and disengagement 
from all association with the lost entity. This stage dif- 
fers from pathological depression in that it represents 
advancement toward resolution rather than the fixa- 
tion in an earlier stage of the grief process. 

• Stage 5 — Acceptance: The final stage brings a feel- 
ing of peace regarding the loss that has occurred. It 
is a time of quiet expectation and resignation. The 
focus is on the reality of the loss and its meaning for 
the individuals affected by it. 

Not all individuals experience each of these stages in 
response to a loss, nor do they necessarily experience 
them in this order. Some individuals' grieving behaviors 
may fluctuate, and even overlap, among the stages. 

Anticipatory Grief 

When a loss is anticipated, individuals often begin the 
work of grieving before the actual loss occurs. This is 
called anticipatory grief. Most people reexperience 
the grieving behaviors once the loss occurs, but having 
this time to prepare for the loss can facilitate the proc- 
ess of mourning, actually decreasing the length and 
intensity of the response. Problems arise, particularly 
in anticipating the death of a loved one, when fam- 
ily members experience anticipatory grieving and the 
mourning process is completed prematurely. They dis- 
engage emotionally from the dying person, who then 
may feel rejected by loved ones at a time when this 
psychological support is so important. 


The grief response can last from weeks to years. It cannot 
be hurried, and individuals must be allowed to progress 
at their own pace. After the loss of a loved one, grief work 
usually lasts for at least a year, during which the grieving 
person experiences each significant "anniversary" date 
for the first time without the loved one present. 

Length of the grief process may be prolonged by 
a number of factors. If the relationship with the lost 
entity had been marked by ambivalence or if there had 
been an enduring "love-hate" association, reaction to 
the loss may be burdened with guilt. Guilt lengthens 

the grief reaction by promoting feelings of anger to- 
ward the self for having committed a wrongdoing or 
behaved in an unacceptable manner toward that which 
is now lost. It may even lead to feeling that one's be- 
havior has contributed to the loss. 

Anticipatory grieving is thought to shorten the grief 
response in some individuals who are able to work 
through some of the feelings before the loss occurs. If 
the loss is sudden and unexpected, mourning may take 
longer than it would if individuals were able to grieve 
in anticipation of the loss. 

Length of the grieving process is also affected by the 
number of recent losses experienced by an individual and 
whether he or she is able to complete one grieving proc- 
ess before another loss occurs. This is particularly true 
for elderly individuals who may be experiencing numer- 
ous losses — such as spouse, friends, other relatives, in- 
dependent functioning, home, personal possessions, and 
pets — in a relatively short time. As grief accumulates, a 
type of bereavement overload occurs, which for some 
individuals presents an impossible task of grief work. 

Resolution of the process of mourning is thought to 
have occurred when an individual can look back on the 
relationship with the lost entity and accept both the 
pleasures and the disappointments (both the positive 
and the negative aspects) of the association (Bowlby 
& Parkes, 1970). Disorganization and emotional pain 
have been experienced and tolerated. Preoccupation 
with the lost entity has been replaced with energy and 
the desire to pursue new situations and relationships. 

Maladaptive Grief Responses 

Maladaptive responses to loss occur when an individual 
is not able to progress satisfactorily through the stages 
of grieving to achieve resolution. Usually in such situa- 
tions, an individual becomes fixed in the denial or anger 
stage of the grief process. Several types of grief respons- 
es have been identified as pathological. They include 
responses that are prolonged, delayed or inhibited, or 
distorted. The prolonged response is characterized by an 
intense preoccupation with memories of the lost entity 
for many years after the loss has occurred. Behaviors 
associated with the stages of denial or anger are mani- 
fested, and disorganization of functioning and intense 
emotional pain related to the lost entity are evidenced. 
In the delayed or inhibited response, the individu- 
al becomes fixed in the denial stage of the grieving 
process. The emotional pain associated with the loss 
is not experienced, but anxiety disorders (e.g., pho- 
bias, hypochondriasis) or sleeping and eating disor- 
ders (e.g., insomnia, anorexia) may be evident. The 

2338_Ch01_001-015.indd 11 

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individual may remain in denial for many years until 
the grief response is triggered by a reminder of the 
loss or even by another, unrelated loss. 

The individual who experiences a distorted response 
is fixed in the anger stage of grieving. In the distort- 
ed response, all the normal behaviors associated with 
grieving, such as helplessness, hopelessness, sadness, 
anger, and guilt, are exaggerated out of proportion to 
the situation. The individual turns the anger inward 
on the self, is consumed with overwhelming despair, 
and is unable to function in normal activities of daily 
living. Pathological depression is a distorted grief 


The APA (2000) endorses case evaluation on a multiax- 
ial system "to facilitate comprehensive and systematic 
evaluation with attention to the various mental disor- 
ders and general medical conditions, psychosocial and 
environmental problems, and level of functioning that 
might be overlooked if the focus were on assessing a 
single presenting problem" (p. 27). Each individual is 
evaluated on five axes. They are defined by the DSM- 
IV-TR in the following manner: 

• Axis I — Clinical Disorders and Other Condi- 
tions That May Be a Focus of Clinical Attention: 

This includes all mental disorders (except personal- 
ity disorders and mental retardation). 

• Axis II — Personality Disorders and Mental 
Retardation: These disorders usually begin in 
childhood or adolescence and persist in a stable 
form into adult life. 

• Axis III — General Medical Conditions: These 
include any current general medical condition that 
is potentially relevant to the understanding or man- 
agement of the individual's mental disorder. 

• Axis IV — Psychosocial and Environmental Prob- 
lems: These are problems that may affect the diag- 
nosis, treatment, and prognosis of mental disorders 
named on axes I and II. These include problems re- 
lated to primary support group, social environment, 
education, occupation, housing, economics, access to 
health-care services, interaction with the legal system 
or crime, and other types of psychosocial and envi- 
ronmental problems. 

• Axis V — Global Assessment of Functioning: This 
allows the clinician to rate the individual's overall 
functioning on the Global Assessment of Function- 
ing (GAF) Scale. This scale represents in global terms 
a single measure of the individual's psychological, 

social, and occupational functioning. A copy of the 
GAF Scale appears in Box 1-2. 

Table 1-2 is an example of a psychiatric diagnosis 
using the multiaxial system. The DSM-IV-TR outline 
of axes I and II categories and codes is presented in 
Appendix A. 


■ For purposes of this text, mental health is defined 
as "the successful adaptation to stressors from the 
internal or external environment, evidenced by 
thoughts, feelings, and behaviors that are age appro- 
priate and congruent with local and cultural norms" 
(Townsend, 2009). 

Mental illness is defined as "maladaptive responses to 
stressors from the internal or external environment, 
evidenced by thoughts, feelings, and behaviors that 
are incongruent with the local and cultural norms 
and interfere with the individual's social, occupation- 
al, and/or physical functioning" (Townsend, 2009). 
Most cultures label behavior as mental illness on the 
basis of incomprehensibility and cultural relativity. 
When observers are unable to find meaning or 
comprehensibility in behavior, they are likely to la- 
bel that behavior as mental illness. The meaning of 
behaviors is determined within individual cultures. 
Selye, who has become known as the founding fa- 
ther of stress research, defined stress as "the state 
manifested by a specific syndrome which consists 
of all the non-specifically induced changes within a 
biological system" (Selye, 1976). 
Selye determined that physical beings respond to 
stressful stimuli with a predictable set of physio- 
logical changes. He described the response in three 
distinct stages: (1) the alarm reaction stage, (2) the 
stage of resistance, and (3) the stage of exhaustion. 
Many illnesses, or diseases of adaptation, have their 
origin in this aroused state, which is the preparation 
for fight or flight. 

Anxiety and grief have been identified as the two ma- 
jor, primary responses to stress. 

Table 1-2 

Example of a Psychiatric 

Axis I 
Axis II 

Axis III 
Axis IV 



Dysthymic Disorder 
Dependent Personality 

GAF = 65 (current) 

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Box 1-2 Global Assessment of Functioning (GAF) Scale 

Consider psychological, social, and occupational function- 
ing on a hypothetical continuum of mental health-illness. 

Do not include impairment in functioning due to physical 
(or environmental) limitations. 









(Note: Use intermediate codes when appropriate, e.g., 45, 68, 72.) 

Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out 
by others because of his or her many positive qualities. No symptoms. 

90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and 

I involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday 

81 problems or concerns (e.g., an occasional argument with family members). 

80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty 

I concentrating after family argument); no more than slight impairment in social, occupational, or school func- 

7 1 tioning (e.g., temporarily falling behind in schoolwork). 

Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or 
school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, 
has some meaningful interpersonal relationships. 

Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in 
social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). 






Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impair- 
ment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). 

40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR 
I major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood 

3 1 ( e -g-> depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, 

is defiant at home, and is failing at school). 

30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication 

I or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to func- 

2 1 tion in almost all areas (e.g., stays in bed all day; no job, home, or friends). 

20 Some degree of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; 

I manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross 

1 1 impairment in communication (e.g., largely incoherent or mute). 

Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain 
minimal personal hygiene OR serious suicidal act with clear expectation of death. 

Inadequate information. 

Source: American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). 
Text Revision. Washington, DC: American Psychiatric Publishing. With permission. 

Peplau (1963) defined anxiety by levels of symptom 
severity: mild, moderate, severe, and panic. 
Behaviors associated with levels of anxiety include 
coping mechanisms, ego defense mechanisms, psy- 
chophysiological responses, psychoneurotic re- 
sponses, and psychotic responses. 
Grief is described as a response to loss of a valued 

Stages of normal mourning as identified by Kiibler- 
Ross (1969) are denial, anger, bargaining, depres- 
sion, and acceptance. 

Anticipatory grief is grief work that is begun, and 
sometimes completed, before the loss occurs. 

Resolution is thought to occur when an individual is 
able to remember and accept both the positive and 
negative aspects associated with the lost entity. 
Grieving is thought to be maladaptive when the 
mourning process is prolonged, delayed or inhib- 
ited, or becomes distorted and exaggerated out of 
proportion to the situation. 

Pathological depression is considered to be a dis- 
torted reaction. 

The DSM-IV-TR multiaxial system of diagnostic 
classification defines five axes in which each indi- 
vidual case is evaluated. 

2338_Ch01_001-015.indd 13 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 

1. Three years ago, Anna's dog Lucky, whom she had had for 16 years, was run over by a car and 
killed. Anna's daughter reports that since that time, Anna has lost weight, rarely leaves her home, 
and just sits and talks about Lucky. Anna's behavior would be considered maladaptive because: 

a. it has been more than 3 years since Lucky died. 

b. her grief is too intense just over the loss of a dog. 

c. her grief is interfering with her functioning. 

d. people in this culture would not comprehend such behavior over loss of a pet. 

2. Based on the information in Question 1, Anna's grieving behavior would most likely be considered 
to be: 

a. delayed. 

b. inhibited. 

c. prolonged. 

d. distorted. 


3. Anna is diagnosed with Major Depression. She is most likely fixed in which stage of the grief 

a. Denial 

b. Anger 

c. Depression 

d. Acceptance 

4. Anna, who is 72 years old, is of the age at which she may have experienced many losses coming 
close together. What is this called? 

a. Bereavement overload 

b. Normal mourning 

c. Isolation 

d. Cultural relativity 

5. Anna, age 72, has been grieving the death of her dog, Lucky, for 3 years. She is not able to take care 
of her activities of daily living, and wants only to make daily visits to Lucky's grave. Her daughter 
has likely put off seeking help for Anna because: 

a. women are less likely to seek help for emotional problems than men are. 

b. relatives often try to "normalize" the behavior, rather than label it mental illness. 

c. she knows that all older people are expected to be a little depressed. 

d. she is afraid that the neighbors "will think her mother is crazy." 

6. Anna's dog Lucky got away from her while they were taking a walk. He ran into the street and was 
hit by a car. Anna cannot remember any of these circumstances of his death. This is an example of 
what defense mechanism? 

a. Rationalization 

b. Suppression 

c. Denial 

d. Repression 

2338_Ch01_001-015.indd 14 

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7. Lucky sometimes refused to obey Anna and, indeed, did not come back to her when she called to 
him on the day he was killed. But Anna continues to insist, "he was the very best dog. He always 
minded me. He always did everything I told him to do." This represents the defense mechanism of: 

a. sublimation. 

b. compensation. 

c. reaction formation. 

d. undoing. 

8. Anna has been a widow for 20 years. Her maladaptive grief response to the loss of her dog may 
attributed to which of the following? Select all that apply. 

a. Unresolved grief over loss of her husband 

b. Loss of several relatives and friends over the last few years 

c. Repressed feelings of guilt over the way in which Lucky died 

d. Inability to prepare in advance for the loss 

9. For what reason would Anna's illness be considered a neurosis rather than a psychosis? 

a. She is unaware that her behavior is maladaptive. 

b. She exhibits inappropriate affect (emotional tone). 

c. She experiences no loss of contact with reality. 

d. She tells the nurse "There is nothing wrong with me!" 

10. Which of the following statements by Anna might suggest that she is achieving resolution of her 
grief over Lucky's death? 

a. "I don't cry anymore when I think about Lucky." 

b. "It's true. Lucky didn't always mind me. Sometimes he ignored my commands." 

c. "I remember how it happened now. I should have held tighter to his leash!" 

d. "I won't ever have another dog. It's just too painful to lose them." 


American Psychiatric Association (APA). (2000). Diagnostic and 

statistical manual of mental disorders (4th ed.). Text revision. 

Washington, DC: American Psychiatric Publishing. 
American Psychiatric Association (APA). (2003). A psychiatric 

(8th ed.). Washington, DC: American Psychiatric Publishing, 
Horwitz, A.V. (2002). The social control of mental illness. Clinton 

Corners, NY: Percheron Press. 

Sadock, B.J., & Sadock, V.A. (2007). Synopsis of psychiatry: Behavioral 
sciences/clinical psychiatry (10th ed.). Baltimore: Lippincott 
Williams & Wilkins. 

Townsend, M.C. (2009). Psychiatric/mental health nursing: Concepts of 
care in evidence-based practice (6th ed.). Philadelphia: F.A. Davis. 


Bowlby, J., & Parkes, CM. (1970). Separation and loss. In 

E.J.Anthony & C. Koupernik (Eds.), International yearbook for 
child psychiatry and allied disciplines: The child and his family (Vol. 1). 
New York: John Wiley & Sons. 

Freud, A. (1953). The ego and mechanisms of defense. New York: Inter- 
national Universities Press. 

Freud, S. (1961). The ego and the id. In Standard edition of the 
complete psychological works of Freud (Vol. XIX). London: Hogarth 

Kiibler-Ross, E. (1969). On death and dying. New York: Macmillan. 

Maslow, A. (1970). Motivation and personality (2nd ed.). New York: 

Harper & Row. 
Menninger, K. (1963). The vital balance. New York: Viking Press. 
Peplau, H. (1963). A working definition of anxiety. In S. Burd & 

M. Marshall (Eds.), Some clinical approaches to psychiatric nursing. 

New York: Macmillan. 
Selye, H. (1956). The stress of life. New York: McGraw-Hill. 
Selye, H. (1974). Stress without distress. New York: Signet Books. 
Selye, H. (1976). The stress of life (rev. ed.). New York: McGraw-Hill. 

2338_Ch01_001-015.indd 15 

8/31/10 5:54:51 PM 


H A P T E R 

Concepts of Personality 














counselor superego 


ego surrogate 

id symbiosis 

libido technical expert 

psychodynamic nursing temperament 


After reading this chapter, the student will be able to: 

1. Define personality. 

2. Identify the relevance of knowledge as- 
sociated with personality development to 
nursing in the psychiatric/mental health 

3. Discuss the major components of the fol- 
lowing developmental theories: 

a. Psychoanalytic theory — Freud 

b. Interpersonal theory — Sullivan 

Theory of psychosocial development- 


Theory of object relations 

development — Mahler 

A nursing model of interpersonal 

development — Peplau 




2338_Ch02_016-032.indd 16 

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Please read the chapter and answer the following questions. 

1. Which part of the personality as described 
by Freud is developed as the child inter- 
nalizes the values and morals set forth by 
primary caregivers? 

2. According to Erikson, what happens when 
the adolescent does not master the tasks 
of identity versus role confusion? 

According to Mahler's theory, the individ- 
ual with borderline personality disorder 
harbors fears of abandonment and under- 
lying rage based on fixation in what stage 
of development? 


The Diagnostic and Statistical Manual of Mental Disorders, 
Fourth Edition, Text Revision (DSM-IV-TR) (American 
Psychiatric Association [APA], 2000) defines personality 
traits as "enduring patterns of perceiving, relating to, 
and thinking about the environment and oneself that 
are exhibited in a wide range of social and personal 
contexts" (p. 686). Nurses must have a basic knowl- 
edge of human personality development to understand 
maladaptive behavioral responses commonly seen in 
psychiatric clients. Developmental theories identify 
behaviors associated with various stages through which 
individuals pass, thereby specifying what is appropriate 
or inappropriate at each developmental level. 

Specialists in child development believe that infancy 
and early childhood are the major life periods for the 
origination and occurrence of developmental change. 
Specialists in life cycle development believe that peo- 
ple continue to develop and change throughout life, 
thereby suggesting the possibility for renewal and 
growth in adults. 

Developmental stages are identified by age. Behav- 
iors can then be evaluated for age appropriateness. 
Ideally, an individual successfully fulfills all the tasks 
associated with one stage before moving on to the 
next stage (at the appropriate age). In reality, how- 
ever, this seldom happens. One reason is related to 
temperament, the inborn personality characteristics 
that influence an individual's manner of reacting to 
the environment and, ultimately, his or her develop- 
mental progression (Chess & Thomas, 1986). The 
environment may also influence one's developmental 
pattern. Individuals who are reared in a dysfunctional 
family system often have retarded ego development. 
According to specialists in life-cycle development, 

behaviors from an unsuccessfully completed stage 
can be modified and corrected in a later stage. 

Stages overlap, and an individual may be working 
on tasks associated with several stages at one time. 
When an individual becomes fixed in a lower level of 
development, with age-inappropriate behaviors fo- 
cused on fulfillment of those tasks, psychopathology 
may become evident. Only when personality traits are 
inflexible and maladaptive and cause either significant 
functional impairment or subjective distress do they 
constitute personality disorders (APA, 2000). 


Sigmund Freud (1961), who has been called the father 
of psychiatry, is credited as the first to identify devel- 
opment by stages. He considered the first 5 years of a 
child's life to be the most important because he believed 
that an individual's basic character had been formed by 
the age of 5. 

Freud's personality theory can be conceptualized 
according to structure and dynamics of the personal- 
ity, topography of the mind, and stages of personality 



The combination of character, behavioral, tempera- 
mental, emotional, and mental traits that is unique 
to each specific individual. 


2338_Ch02_016-032.indd 17 

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Structure of the Personality 

Freud organized the structure of the personality into 
three major components: the id, ego, and superego. 
They are distinguished by their unique functions and 
different characteristics. 


The id is the locus of instinctual drives — the "pleasure 
principle." Present at birth, it endows the infant with 
instinctual drives that seek to satisfy needs and achieve 
immediate gratification. Id-driven behaviors are im- 
pulsive and may be irrational. 


The ego, also called the rational self or the "reality prin- 
ciple," begins to develop between the ages of 4 and 
6 months. The ego experiences the reality of the ex- 
ternal world, adapts to it, and responds to it. As the 
ego develops and gains strength, it seeks to bring the 
influences of the external world to bear upon the id, to 
substitute the reality principle for the pleasure princi- 
ple (Marmer, 2003). A primary function of the ego is 
one of mediator, that is, to maintain harmony among 
the external world, the id, and the superego. 


If the id is identified as the pleasure principle, and the 
ego the reality principle, the superego might be referred 
to as the "perfection principle." The superego, which 
develops between ages 3 and 6 years, internalizes the 
values and morals set forth by primary caregivers. 
Derived from a system of rewards and punishments, 
the superego is composed of two major components: 
the ego-ideal and the conscience. When a child is consist- 
ently rewarded for "good" behavior, the self-esteem 
is enhanced, and the behavior becomes part of the 
ego-ideal; that is, it is internalized as part of his or her 
value system. The conscience is formed when the child 
is consistently punished for "bad" behavior. The child 
learns what is considered morally right or wrong from 
feedback received from parental figures and from so- 
ciety or culture. When moral and ethical principles or 
even internalized ideals and values are disregarded, the 
conscience generates a feeling of guilt within the indi- 
vidual. The superego is important in the socialization 
of the individual because it assists the ego in the control 
of id impulses. When the superego becomes rigid and 
punitive, however, problems with low self-confidence 
and low self-esteem arise. 

For behavioral examples of id, ego, and superego, 
see Table 2-1. 

Topography of the Mind 

Freud classified all mental contents and operations 
into three categories: the conscious, the preconscious, 
and the unconscious. 

• The conscious includes all memories that remain 
within an individual's awareness. It is the smallest of 
the three categories. Events and experiences that are 
easily remembered or retrieved are considered to be 
within one's conscious awareness. Examples include 
telephone numbers, birthdays of self and significant 
others, dates of special holidays, and what one had 
for lunch today. The conscious mind is thought to 
be under the control of the ego, the rational and 
logical structure of the personality. 

• The preconscious includes all memories that may 
have been forgotten or are not in present awareness 
but, with attention, can readily be recalled into con- 
sciousness. Examples include telephone numbers or 
addresses once known but little used and feelings 
associated with significant life events that may have 
occurred at some time in the past. The preconscious 
enhances awareness by helping to suppress unpleas- 
ant or nonessential memories from consciousness. 
It is thought to be partially under the control of 
the superego, which helps to suppress unacceptable 
thoughts and behaviors. 

• The unconscious includes all memories that one is 
unable to bring to conscious awareness. It is the 

Table 2-1 

Structure of the Personality 

Behavioral Examples 




"I found this wal- 

"I already have 

"It is never 

let; I will keep 

money. This 

right to take 

the money." 

money doesn't 

something that 

belong to me. 

doesn't belong 

Maybe the 

to you." 

person who 

owns this wallet 

doesn't have any 


"Mom and Dad 

"Mom and Dad 

"Never disobey 

are gone. Let's 

said no friends 

your parents." 


over while they 
are away. Too 

"I'll have sex with 

"Promiscuity can 

"Sex outside of 

whomever I 

be very danger- 

marriage is 

please, when- 


always wrong." 

ever I please." 

2338_Ch02_016-032.indd 18 

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Chapter 2 



largest of the three topographical levels. Uncon- 
scious material consists of unpleasant or nonessen- 
tial memories that have been repressed and can be 
retrieved only through therapy, hypnosis, and with 
certain substances that alter the awareness and have 
the capacity to restructure repressed memories. 
Unconscious material may also emerge in dreams 
and in seemingly incomprehensible behavior. 

Dynamics of the Personality 

Freud believed that psychic energy is the force or im- 
petus required for mental functioning. Originating in 
the id, it instinctually fulfills basic physiological needs. 
Freud called this psychic energy (or the drive to fulfill 
basic physiological needs such as hunger, thirst, and 
sex) the libido. As the child matures, psychic energy 
is diverted from the id to form the ego and then from 
the ego to form the superego. Psychic energy is dis- 
tributed within these three components, with the ego 
retaining the largest share to maintain a balance be- 
tween the impulsive behaviors of the id and the ideal- 
istic behaviors of the superego. If an excessive amount 
of psychic energy is stored in one of these personality 
components, behavior reflects that part of the person- 
ality. For instance, impulsive behavior prevails when 
excessive psychic energy is stored in the id. Overin- 
vestment in the ego reflects self-absorbed, or narcis- 
sistic, behaviors; an excess within the superego results 
in rigid, self-deprecating behaviors. 

Freud used the terms cathexis and anticathexis to de- 
scribe the forces within the id, ego, and superego that 
are used to invest psychic energy in external sources to 
satisfy needs. Cathexis is the process by which the id 
invests energy into an object in an attempt to achieve 
gratification. An example is the individual who instinc- 
tively turns to alcohol to relieve stress. Anticathexis is 
the use of psychic energy by the ego and the super- 
ego to control id impulses. In the example cited, the 
ego would attempt to control the use of alcohol with 
rational thinking, such as, "I already have ulcers from 
drinking too much. I will call my AA sponsor for sup- 
port. I will not drink." The superego would exert con- 
trol with such thinking as, "I shouldn't drink. If I drink, 
my family will be hurt and angry. I should think of how 
it affects them. I'm such a weak person." Freud believed 
that an imbalance between cathexis and anticathexis 
resulted in internal conflicts, producing tension and 
anxiety within the individual. Freud's daughter Anna 
devised a comprehensive list of defense mechanisms 
believed to be used by the ego as a protective device 
against anxiety in mediating between the excessive de- 
mands of the id and the excessive restrictions of the 
superego (see Chapter 1). 

Freud's Stages of Personality 

Freud described formation of the personality through 
five stages of psychosexual development. He placed 
much emphasis on the first 5 years of life and be- 
lieved that characteristics developed during these 
early years bore heavily on one's adaptation patterns 
and personality traits in adulthood. Fixation in an 
early stage of development almost certainly results 
in psychopathology. An outline of these five stages is 
presented in Table 2-2. 

Oral Stage: Birth to 18 Months 

During the oral stage, behavior is directed by the id, 
and the goal is immediate gratification of needs. The 
focus of energy is the mouth, and behaviors include 
sucking, chewing, and biting. The infant feels a sense 
of attachment and is unable to differentiate the self 
from the person who is providing the mothering. This 
includes feelings such as anxiety. Because of this lack 
of differentiation, a pervasive feeling of anxiety on the 
part of the mother may be passed on to her infant, 
leaving the child vulnerable to similar feelings of in- 
security. With the beginning of development of the 
ego at age 4 to 6 months, the infant starts to view the 
self as separate from the mothering figure. A sense of 
security and the ability to trust others are derived out 

■ ABLE 2-2 

Freud's Stages of 
Psychosexual Development 



Major Developmental 

Birth- 18 months 


Relief from anxiety 
through oral gratifica- 
tion of needs 

18 months-3 years 


Learning independence 
and control, with focus 
on the excretory 

3-6 years 


Identification with parent 
of same gender; develop- 
ment of sexual identity; 
focus on genital organs 

6-12 years 


Sexuality repressed; focus 
on relationships with 
same-gender peers 

13-20 years 


Libido reawakened as 
genital organs mature; 
focus on relationships 
with members of the 
opposite gender 

2338_Ch02_016-032.indd 19 

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of gratification from fulfillment of basic needs during 
this stage. 

Anal Stage: 18 Months to 3 Years 

The major task in the anal stage is gaining independ- 
ence and control, with particular focus on the excreto- 
ry function. Freud believed that the manner in which 
the parents and other primary caregivers approach the 
task of toilet training may have far-reaching effects on 
the child in terms of values and personality charac- 
teristics. When toilet training is strict and rigid, the 
child may choose to retain the feces, becoming consti- 
pated. Adult retentive personality traits influenced by 
this type of training include stubbornness, stinginess, 
and miserliness. An alternate reaction to strict toilet 
training is for the child to expel feces in an unaccept- 
able manner or at inappropriate times. Far-reaching 
effects of this behavior pattern include malevolence, 
cruelty to others, destructiveness, disorganization, 
and untidiness. 

Toilet training that is more permissive and accept- 
ing attaches the feeling of importance and desirability 
to feces production. The child becomes extroverted, 
productive, and altruistic. 

Phallic Stage: 3 to 6 Years 

In this stage, the focus of energy shifts to the genital 
area. Discovery of differences between genders results 
in a heightened interest in the sexuality of self and 
others. This interest may be manifested in sexual self- 
exploratory or group- exploratory play. Freud proposed 
that the development of the Oedipus complex (males) or 
Electra complex (females) occurred during this stage of 
development. He described this as the child's uncon- 
scious desire to eliminate the parent of the same gender 
and to possess the parent of the opposite gender for 
himself or herself. Guilt feelings result with the emer- 
gence of the superego during these years. Resolution of 
this internal conflict occurs when the child develops a 
strong identification with the parent of the same gen- 
der and internalizes that parent's attitudes, beliefs, and 
value system. 

Latency Stage: 6 to 12 Years 

During the elementary school years, the focus changes 
from egocentrism to one of more interest in group ac- 
tivities, learning, and socialization with peers. Sexuali- 
ty is not absent during this period but remains obscure 
and imperceptible to others. Children of this age show 

a distinct preference for same-gender relationships, 
even rejecting members of the opposite gender. 

Genital Stage: 13 to 20 Years 

In the genital stage, the maturing of the genital organs 
results in a reawakening of the libidinal drive. The focus 
is on relationships with members of the opposite gen- 
der and preparations for selecting a mate. The develop- 
ment of sexual maturity evolves from self-gratification 
to behaviors deemed acceptable by societal norms. In- 
terpersonal relationships are based on genuine pleasure 
derived from the interaction rather than from the more 
self-serving implications of childhood associations. 

Relevance of Psychoanalytic Theory 
to Nursing Practice 

Knowledge of the structure of the personality can as- 
sist nurses who work in the mental health setting. The 
ability to recognize behaviors associated with the id, the 
ego, and the superego assists in the assessment of devel- 
opmental level. Understanding the use of ego defense 
mechanisms is important in making determinations 
about maladaptive behaviors, in planning care for clients 
to assist in creating change (if desired), or in helping cli- 
ents accept themselves as unique individuals. 


Sullivan (1953) believed that individual behavior and 
personality development are the direct result of inter- 
personal relationships. Before the development of his 
own theoretical framework, Sullivan embraced the con- 
cepts of Freud. Later, he changed the focus of his work 
from the intrapersonal view of Freud to one with a more 
interpersonal flavor in which human behavior could be 
observed in social interactions with others. His ideas, 
which were not universally accepted at the time, have 
been integrated into the practice of psychiatry through 
publication only since his death in 1949. Sullivan's ma- 
jor concepts include the following: 

• Anxiety is a feeling of emotional discomfort, to- 
ward the relief or prevention of which all behavior 
is aimed. Sullivan believed that anxiety is the "chief 
disruptive force in interpersonal relations and the 
main factor in the development of serious difficul- 
ties in living." It arises out of one's inability to satisfy 
needs or achieve interpersonal security. 

• Satisfaction of needs is the fulfillment of all require- 
ments associated with an individual's physiochemi- 
cal environment. Sullivan identified examples of 

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Chapter 2 



these requirements as oxygen, food, water, warmth, 
tenderness, rest, activity, sexual expression — virtually 
anything that, when absent, produces discomfort in 
the individual. 

• Interpersonal security is the feeling associated with 
relief from anxiety. When all needs have been met, 
one experiences a sense of total well-being, which 
Sullivan termed interpersonal security. He believed 
individuals have an innate need for interpersonal 

• Self-system is a collection of experiences, or secu- 
rity measures, adopted by the individual to protect 
against anxiety. Sullivan identified three compo- 
nents of the self-system, which are based on inter- 
personal experiences early in life: 

The "good me" is the part of the personality that 
develops in response to positive feedback from the 
primary caregiver. Feelings of pleasure, content- 
ment, and gratification are experienced. The child 
learns which behaviors elicit this positive response 
as it becomes incorporated into the self-system. 
The "bad me" is the part of the personality that 
develops in response to negative feedback from 
the primary caregiver. Anxiety is experienced, 
eliciting feelings of discomfort, displeasure, and 
distress. The child learns to avoid these negative 
feelings by altering certain behaviors. 
The "not me" is the part of the personality that 
develops in response to situations that produce 
intense anxiety in the child. Feelings of horror, 
awe, dread, and loathing are experienced in re- 
sponse to these situations, leading the child to 
deny these feelings in an effort to relieve anxiety. 
These feelings, having then been denied, become 
"not me," but someone else. This withdrawal 
from emotions has serious implications for men- 
tal disorders in adult life. 

Sullivan's Stages of Personality 

Sullivan describes six stages of personality develop- 
ment. An outline of the stages of personality develop- 
ment according to Sullivan's interpersonal theory is 
presented in Table 2-3. 

Infancy: Birth to 18 Months 

During this beginning stage, the major developmen- 
tal task for the child is the gratification of needs. This 
is accomplished through activity associated with the 
mouth, such as crying, nursing, and thumb sucking. 

Stages of D< 


in Sullivan's 

Age Stage 




Birth- 18 months Infancy 

Relief from anxiety 
through oral gratifi- 
cation of needs 

1 8 months-6 years Childhood 

6-9 years 


Learning to experi- 
ence a delay in 
personal gratifica- 
tion without undue 

Learning to form 
satisfactory peer 

9-12 years 


12-14 years 



Learning to form sat- 
isfactory relation- 
ships with persons 
of same gender 
initiating feelings 
of affection for 
another person 

Learning to form sat- 
isfactory relation- 
ships with persons 
of the opposite 
gender; developing 
a sense of identity 

14-21 years 



Establishing self- 
identity; experienc- 
ing satisfying rela- 
tionships; working 
to develop a lasting, 
intimate opposite- 
gender relationship 

Childhood: 18 Months to 6 Years 

At ages 18 months to 6 years, the child learns that 
interference with fulfillment of personal wishes and 
desires may result in delayed gratification. He or 
she learns to accept this and feel comfortable with 
it, recognizing that delayed gratification often re- 
sults in parental approval, a more lasting type of 
reward. Tools of this stage include the mouth, the 
anus, language, experimentation, manipulation, and 

Juvenile: 6 to 9 Years 

The major task of the juvenile stage is formation of 
satisfactory relationships within the peer group. This 

2338_Ch02_016-032.indd 21 

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is accomplished through the use of competition, 
cooperation, and compromise. 

Preadolescence: 9 to 12 Years 

The tasks of the preadolescence stage focus on devel- 
oping relationships with persons of the same gender. 
One's ability to collaborate with and show love and af- 
fection for another person begins at this stage. 

Early Adolescence: 12 to 14 Years 

During early adolescence, the child is struggling with 
developing a sense of identity, separate and independ- 
ent from the parents. The major task is formation of 
satisfactory relationships with members of the op- 
posite gender. Sullivan saw the emergence of lust in 
response to biological changes as a major force occur- 
ring during this period. 

Late Adolescence: 14 to 21 Years 

The late adolescent period is characterized by tasks 
associated with the attempt to achieve interdepend- 
ence within the society and the formation of a lasting, 
intimate relationship with a selected member of the 
opposite gender. The genital organs are the major de- 
velopmental focus of this stage. 

Relevance of Interpersonal Theory 
to Nursing Practice 

The interpersonal theory has significant relevance to 
nursing practice. Relationship development, which is 
a major concept of this theory, is a major psychiatric 
nursing intervention. Nurses develop therapeutic rela- 
tionships with clients in an effort to help them gener- 
alize this ability to interact successfully with others. 

Knowledge about the behaviors associated with all 
levels of anxiety and methods for alleviating anxiety 
helps nurses to assist clients achieve interpersonal secu- 
rity and a sense of well-being. Nurses use the concepts 
of Sullivan's theory to help clients achieve a higher de- 
gree of independent and interpersonal functioning. 


Erikson (1963) studied the influence of social process- 
es on the development of the personality. He described 
eight stages of the life cycle during which individu- 
als struggle with developmental "crises." Specific tasks 

associated with each stage must be completed for reso- 
lution of the crisis and for emotional growth to occur. 
An outline of Erikson 's stages of psychosocial develop- 
ment is presented in Table 2-4. 

Erikson's Stages of Personality 

Trust Versus Mistrust: Birth 
to 18 Months 

Major Developmental Task 

In this stage, the major task is to develop a basic trust 
in the mothering figure and be able to generalize it to 

• Achievement of the task results in self-confidence, 
optimism, faith in the gratification of needs and de- 
sires, and hope for the future. The infant learns to 
trust when basic needs are met consistently. 

• Nonachievement results in emotional dissatisfac- 
tion with the self and others, suspiciousness, and 
difficulty with interpersonal relationships. The task 
remains unresolved when primary caregivers fail to 
respond to the infant's distress signal promptly and 

Autonomy Versus Shame and Doubt: 
18 Months to 3 Years 

Major Developmental Task 

The major task in this stage is to gain some self-control 
and independence within the environment. 

• Achievement of the task results in a sense of self- 
control and the ability to delay gratification, and a 
feeling of self-confidence in one's ability to perform. 
Autonomy is achieved when parents encourage and 
provide opportunities for independent activities. 

• Nonachievement results in a lack of self-confidence, 
a lack of pride in the ability to perform, a sense of be- 
ing controlled by others, and a rage against the self. 
The task remains unresolved when primary caregiv- 
ers restrict independent behaviors, both physically 
and verbally, or set the child up for failure with unre- 
alistic expectations. 

Initiative Versus Guilt: 3 to 6 Years 

Major Developmental Task 

During this stage the goal is to develop a sense of pur- 
pose and the ability to initiate and direct one's own 

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Table 2- 

Stages of Development in Erikson's Psychosocial Theory 



(Birth- 18 months) 
Early childhood 
(18 months- 3 years) 


Trust vs. mistrust 

Autonomy vs. shame and doubt 

Major Developmental Tasks 

To develop a basic trust in the mothering figure and be able to gener- 
alize it to others 
To gain some self-control and independence within the environment 

Late childhood 
(3-6 years) 

Initiative vs. guilt 

To develop a sense of purpose and the ability to initiate and direct 
own activities 

School age 
(6-12 years) 

Industry vs. inferiority 

To achieve a sense of self-confidence by learning, competing, per- 
forming successfully, and receiving recognition from significant 
others, peers, and acquaintances 

(12-20 years) 

Identity vs. role confusion 

To integrate the tasks mastered in the previous stages into a secure 
sense of self 

Young adulthood 
(20-30 years) 

Intimacy vs. isolation 

To form an intense, lasting relationship or a commitment to another 
person, cause, institution, or creative effort 

(30-65 years) 

Generativity vs. stagnation 

To achieve the life goals established for oneself, while also consider- 
ing the welfare of future generations 

Old age 

(65 years-death) 

Ego integrity vs. despair 

To review one's life and derive meaning from both positive and 
negative events, while achieving a positive sense of self-worth 

• Achievement of the task results in the ability to exer- 
cise restraint and self-control of inappropriate social 
behaviors. Assertiveness and dependability increase, 
and the child enjoys learning and personal achieve- 
ment. The conscience develops, thereby control- 
ling the impulsive behaviors of the id. Initiative is 
achieved when creativity is encouraged and per- 
formance is recognized and positively reinforced. 

• Nonachievement results in feelings of inadequacy 
and a sense of defeat. Guilt is experienced to an ex- 
cessive degree, even to the point of accepting liabil- 
ity in situations for which one is not responsible. 
The child may view himself or herself as evil and 
deserving of punishment. The task remains unre- 
solved when creativity is stifled and parents contin- 
ually expect a higher level of achievement than the 
child produces. 

Industry Versus Inferiority: 6 to 12 Years 

Major Developmental Task 

The major task of this stage is to achieve a sense of 
self-confidence by learning, competing, performing 
successfully, and receiving recognition from significant 
others, peers, and acquaintances. 

• Achievement of the task results in a sense of satisfac- 
tion and pleasure in the interaction and involvement 
with others. The individual masters reliable work 
habits and develops attitudes of trustworthiness. 
He or she is conscientious, feels pride in achieve- 
ment, and enjoys play, but desires a balance between 

fantasy and "real-world" activities. Industry is 
achieved when encouragement is given to activities 
and responsibilities in the school and community, 
as well as those within the home, and recognition is 
given for accomplishments. 

Nonachievement results in difficulty in interper- 
sonal relationships because of feelings of personal 
inadequacy. The individual can neither cooperate 
and compromise with others in group activities nor 
problem solve or complete tasks successfully. He or 
she may become either passive and meek or overly 
aggressive to cover up feelings of inadequacy. If this 
occurs, the individual may manipulate or violate the 
rights of others to satisfy his or her own needs or 
desires; he or she may become a workaholic with 
unrealistic expectations for personal achievement. 
This task remains unresolved when parents set un- 
realistic expectations for the child, when discipline 
is harsh and tends to impair self-esteem, and when 
accomplishments are consistently met with negative 

Identity Versus Role Confusion: 
12 to 20 Years 

Major Developmental Task 

At this stage, the goal is to integrate the tasks mastered 
in the previous stages into a secure sense of self. 

• Achievement of the task results in a sense of confi- 
dence, emotional stability, and a view of the self as 

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a unique individual. Commitments are made to a 
value system, to the choice for a career, and to re- 
lationships with members of both genders. Identity 
is achieved when adolescents are allowed to experi- 
ence independence by making decisions that influ- 
ence their lives. Parents should be available to offer 
support when needed, but should gradually relin- 
quish control to the maturing individual in an effort 
to encourage the development of an independent 
sense of self. 

Nonachievement results in a sense of self- 
consciousness, doubt, and confusion about one's 
role in life. Personal values or goals for one's life are 
absent. Commitments to relationships with others 
are nonexistent or superficial and brief. A lack of 
self-confidence is often expressed by delinquent 
and rebellious behavior. Entering adulthood, with 
its accompanying responsibilities, may be an un- 
derlying fear. This task can remain unresolved for 
many reasons. Examples include the following: 
When independence is discouraged by the parents 
and the adolescent is nurtured in the dependent 

When discipline within the home has been overly 
harsh, inconsistent, or absent 
When there has been parental rejection or fre- 
quent shifting of parental figures 

Intimacy Versus Isolation: 20 to 30 Years 

Major Developmental Task 

The objective during this stage is to form an intense, 
lasting relationship or a commitment to another per- 
son, a cause, an institution, or a creative effort (Murray, 
Zentner, & Yakimo, 2008). 

• Achievement of the task results in the capacity for 
mutual love and respect between two people and 
the ability of an individual to pledge a total com- 
mitment to another. The intimacy goes far beyond 
the sexual contact between two people. It describes 
a commitment in which personal sacrifices are made 
for another, whether it be another person, or if one 
chooses, a career or other type of cause or endeavor 
to which an individual elects to devote his or her 
life. Intimacy is achieved when an individual has de- 
veloped the capacity for giving of oneself to another. 
This is learned when one has been the recipient of 
this type of giving within the family unit. 

• Nonachievement results in withdrawal, social iso- 
lation, and aloneness. The individual is unable to 

form lasting, intimate relationships, often seeking 
intimacy through numerous superficial sexual con- 
tacts. No career is established; he or she may have a 
history of occupational changes (or may fear change 
and thus remain in an undesirable job situation). 
The task remains unresolved when love in the home 
has been deprived or distorted through the younger 
years (Murray et al, 2008). One fails to achieve the 
ability to give of the self without having been the 
recipient early on from primary caregivers. 

Generativity Versus Stagnation 
or Self-Absorption: 30 to 65 Years 

Major Developmental Task 

The major task of this stage is to achieve the life goals 
established for oneself while also considering the wel- 
fare of future generations. 

• Achievement of the task results in a sense of gratifi- 
cation from personal and professional achievements 
and from meaningful contributions to others. The 
individual is active in the service of and to society. 
Generativity is achieved when the individual ex- 
presses satisfaction with this stage in life and dem- 
onstrates responsibility for leaving the world a better 
place in which to live. 

• Nonachievement results in lack of concern for the 
welfare of others and total preoccupation with the 
self. He or she becomes withdrawn, isolated, and 
highly self-indulgent, with no capacity for giving 
of the self to others. The task remains unresolved 
when earlier developmental tasks are not fulfilled 
and the individual does not achieve the degree of 
maturity required to derive gratification out of a 
personal concern for the welfare of others. 

Ego Integrity Versus Despair: 
65 Years to Death 

Major Developmental Task 

During this stage, the goal is to review one's life and 
derive meaning from both positive and negative events, 
while achieving a positive sense of self. 

• Achievement of the task results in a sense of self- 
worth and self-acceptance as one reviews life goals, 
accepting that some were achieved and some were 
not. The individual derives a sense of dignity from 
his or her life experiences and does not fear death, 

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rather viewing it as another stage of development. 
Ego integrity is achieved when individuals have suc- 
cessfully completed the developmental tasks of the 
other stages and have little desire to make major 
changes in the ways their lives have progressed. 
• Nonachievement results in a sense of self-contempt 
and disgust with how life has progressed. The in- 
dividual would like to start over and have a second 
chance at life. He or she feels worthless and help- 
less to change. Anger, depression, and loneliness are 
evident. The focus may be on past failures or per- 
ceived failures. Impending death is feared or denied, 
or ideas of suicide may prevail. The task remains 
unresolved when earlier tasks are not fulfilled: self- 
confidence, a concern for others, and a strong sense 
of self-identity were never achieved. 

Relevance of Psychosocial Development 
Theory to Nursing Practice 

Erikson's theory is particularly relevant to nursing 
practice in that it incorporates sociocultural con- 
cepts into the development of personality. Erikson 
provides a systematic, stepwise approach and outlines 
specific tasks that should be completed during each 
stage. This information can be used quite readily in 
psychiatric/mental health nursing. Many individu- 
als with mental health problems are still struggling 
to achieve tasks from a number of developmental 
stages. Nurses can plan care to assist these individu- 
als to complete these tasks and move on to a higher 
developmental level. 

■ ABLE 2-5 

Stages of Development in 
Mahler's Theory of Object 


Major Developmental 





I. Normal 

Fulfillment of basic needs 



for survival and comfort 


II. Symbiosis 

Development of awareness 


of external source of 
need fulfillment 


III. Separation- 



a. Differen- 

Commencement of a 


primary recognition of 
separateness from the 
mothering figure 


b. Practicing 

Increased independence 


through locomotor func- 
tioning; increased sense 
of separateness of self 


c. Rapproche- 

Acute awareness of sepa- 



rateness of self; learning 
to seek "emotional 
refueling" from mother- 
ing figure to maintain 
feeling of security 


d. Consolida- 

Sense of separateness 



established; on the way 
to object constancy (i.e., 
able to internalize a 
sustained image of loved 
object/person when it is 
out of sight); resolution 
of separation anxiety 


Mahler (Mahler, Pine, & Bergman, 1975) formulated 
a theory that describes the separation-individuation 
process of the infant from the maternal figure (prima- 
ry caregiver). She describes this process as progressing 
through three major phases, and she further delineates 
phase III, the separation-individuation phase, into four 
subphases. Mahler's developmental theory is outlined 
in Table 2-5. 

Phase I: The Autistic Phase 
(Birth to 1 Month) 

In the autistic phase, also called normal autism, the 
infant exists in a half-sleeping, half-waking state and 
does not perceive the existence of other people or an 
external environment. The fulfillment of basic needs 
for survival and comfort is the focus and is merely ac- 
cepted as it occurs. 

Phase II: The Symbiotic Phase 
(1 to 5 Months) 

Symbiosis is a type of "psychic fusion" of mother and 
child. The child views the self as an extension of the 
mother but with a developing awareness that it is she 
who fulfills the child's every need. Mahler suggests that 
absence of, or rejection by, the maternal figure at this 
phase can lead to symbiotic psychosis. 

Phase III: Separation-individuation 
(5 to 36 Months) 

This third phase represents what Mahler calls the 
"psychological birth" of the child. Separation is defined 
as the physical and psychological attainment of a sense 
of personal distinction from the mothering figure. In- 
dividuation occurs with a strengthening of the ego and 
an acceptance of a sense of "self," with independent 
ego boundaries. Four subphases through which the 

2338_Ch02_016-032.indd 25 

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child evolves in his or her progression from a symbi- 
otic extension of the mothering figure to a distinct and 
separate being are described. 

Subphase 1 — Differentiation 
(5 to 10 Months) 

The differentiation phase begins with the child's initial 
physical movements away from the mothering figure. 
A primary recognition of separateness commences. 

Subphase 2 — Practicing 
(10 to 16 Months) 

With advanced locomotor functioning, the child experi- 
ences feelings of exhilaration from increased independ- 
ence. He or she is now able to move away from, and 
return to, the mothering figure. A sense of omnipotence 
is manifested. 

and "bad." A degree of object constancy is established 
as the child is able to internalize a sustained image of 
the mothering figure as enduring and loving, while 
maintaining the perception of her as a separate person 
in the outside world. 

Relevance of Object Relations Theory 
to Nursing Practice 

Understanding of the concepts of Mahler's theory of 
object relations helps the nurse assess the client's level 
of individuation from primary caregivers. The emotion- 
al problems of many individuals can be traced to lack 
of fulfillment of the tasks of separation-individuation. 
Examples include problems related to dependency and 
excessive anxiety. The individual with borderline person- 
ality disorder is thought to be fixed in the rapprochement 
phase of development, harboring fears of abandonment 
and underlying rage. This knowledge is important in the 
provision of nursing care to these individuals. 

Subphase 3 — Rapprochement 
(16 to 24 Months) 

This third subphase, rapprochement, is extremely 
critical to the child's healthy ego development. During 
this time, the child becomes increasingly aware of his 
or her separateness from the mothering figure, while 
the sense of fearlessness and omnipotence diminishes. 
The child, now recognizing the mother as a separate 
individual, wishes to reestablish closeness with her but 
shuns the total re-engulfment of the symbiotic stage. 
The child needs the mothering figure to be available 
to provide "emotional refueling" on demand. 

Critical to this subphase is the mothering figure's 
response to the child. If the mothering figure is avail- 
able to fulfill emotional needs as they are required, the 
child develops a sense of security in the knowledge 
that he or she is loved and will not be abandoned. 
However, if emotional needs are inconsistently met or 
if the mother rewards clinging, dependent behaviors 
and withholds nurturing when the child demonstrates 
independence, feelings of rage and fear of abandon- 
ment develop and often persist into adulthood. 

Subphase 4 — Consolidation 
(24 to 36 Months) 

With achievement of the consolidation subphase, a 
definite individuality and sense of separateness of self 
are established. Objects are represented as whole, with 
the child having the ability to integrate both "good" 



Peplau (1991) applied interpersonal theory to nursing 
practice and, most specifically, to nurse-client relation- 
ship development. She established a framework for 
psychodynamic nursing, the interpersonal involve- 
ment of the nurse with a client in a given nursing situ- 
ation. Peplau stated, "Nursing is helpful when both the 
patient and the nurse grow as a result of the learning 
that occurs in the nursing situation." 

Peplau correlated the stages of personality devel- 
opment in childhood to stages through which clients 
advance during the progression of an illness. She also 
viewed these interpersonal experiences as learning situ- 
ations for nurses to facilitate forward movement in the 
development of personality. She believed that when 
there is fulfillment of psychological tasks associated 
with the nurse-client relationship, the personalities of 
both can be strengthened. Key concepts include the fol- 

• Nursing is a human relationship between an indi- 
vidual who is sick or in need of health services and 
a nurse especially educated to recognize and to re- 
spond to the need for help. 

• Psychodynamic nursing is being able to understand 
one's own behavior, to help others identify felt 
difficulties, and to apply principles of human re- 
lations to the problems that arise at all levels of 

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• Roles are sets of values and behaviors that are spe- 
cific to functional positions within social structures. 
Peplau identified the following nursing roles: 

A resource person is one who provides specific, 
needed information that helps the client under- 
stand his or her problem and the new situation. 
A counselor is one who listens as the client re- 
views feelings related to difficulties he or she is 
experiencing in any aspect of life. "Interpersonal 
techniques" have been identified to facilitate the 
nurse's interaction in the process of helping the 
client solve problems and make decisions con- 
cerning these difficulties. 

A teacher is one who identifies learning needs and 
provides information to the client or family that 
may aid in improvement of the life situation. 
1 A leader is one who directs the nurse- client inter- 
action and ensures that appropriate actions are 
undertaken to facilitate achievement of the des- 
ignated goals. 

A technical expert is one who understands vari- 
ous professional devices and possesses the clini- 
cal skills necessary to perform the interventions 
that are in the best interest of the client. 
A surrogate is one who serves as a substitute fig- 
ure for another. 

Phases of the nurse-client relationship are stages of 
overlapping roles or functions in relation to health 
problems, during which the nurse and client learn to 
work cooperatively to resolve difficulties. Peplau iden- 
tified four phases: 

• Orientation is the phase during which the client, 
nurse, and family work together to recognize, clari- 
fy, and define the existing problem. 

• Identification is the phase after which the client's ini- 
tial impression has been clarified and during which 
he or she begins to respond selectively to persons 
who seem to offer the help that is needed. Clients 
may respond in one of three ways: (1) on the basis of 
participation or interdependent relations with the 
nurse, (2) on the basis of independence or isolation 
from the nurse, or (3) on the basis of helplessness or 
dependence on the nurse (Peplau, 1991). 

• Exploitation is the phase during which the client 
proceeds to take fall advantage of the services of- 
fered to him or her. Having learned which services 
are available, feeling comfortable within the set- 
ting, and serving as an active participant in his or 
her own health care, the client exploits the services 
available and explores all possibilities of the chang- 
ing situation. 

• Resolution occurs when the client is freed from iden- 
tification with helping persons and gathers strength 
to assume independence. Resolution is the direct 
result of successful completion of the other three 

Peplau's Stages of Personality 

Psychological tasks are developmental lessons that must 
be learned on the way to achieving maturity of the 
personality. Peplau (1991) identified four psychologi- 
cal tasks that she associated with the stages of infancy 
and childhood described by Freud and Sullivan. She 

When psychological tasks are successfully learned at 
each era of development, biological capacities are used 
productively and relations with people lead to produc- 
tive living. When they are not successfully learned they 
carry over into adulthood and attempts at learning 
continue in devious ways, more or less impeded by 
conventional adaptations that provide a super-structure 
over the baseline of actual learning, (p. 166) 

In the context of nursing, Peplau (1991) related these 
four psychological tasks to the demands made on nurs- 
es in their relations with clients. She maintained that 

. . . nursing can function as a maturing force in society. 
Since illness is an event that is experienced along with 
feelings that derive from older experiences but are 
reenacted in the relationship of nurse to patient, the 
nurse-patient relationship is seen as an opportunity for 
nurses to help patients to complete the unfinished psy- 
chological tasks of childhood in some degree, (p. 159) 

Peplau's psychological tasks of personality develop- 
ment include the following four stages. An outline of 
the stages of personality development according to 
Peplau's theory is presented in Table 2-6. 

Learning to Count on Others 

Nurses and clients first come together as strangers. 
Both bring to the relationship certain "raw materials," 
such as inherited biological components, personality 
characteristics (temperament), individual intellectual 
capacity, and specific cultural or environmental influ- 
ences. Peplau related these to the same "raw materi- 
als" with which an infant comes into this world. The 
newborn is capable of experiencing comfort and discom- 
fort. He or she soon learns to communicate feelings in 
a way that results in the fulfillment of comfort needs 
by the mothering figure who provides love and care 

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Table 2- 

Stages of Development 
in Peplau's Interpersonal 



Major Developmental 


Learning to 

Learning to communicate 

count on 

in various ways with 


the primary caregiver 
to have comfort needs 


to delay 

Learning the satisfaction of 
pleasing others by delay- 
ing self-gratification in 
small ways 




Learning appropriate 
roles and behaviors by 
acquiring the ability to 
perceive the expectations 
of others 



skills in par- 

Learning the skills of 
compromise, competi- 


tion, and cooperation 
with others; establishing 
a more realistic view of 
the world and a feeling 
of one's place in it 

unconditionally. However, fulfillment of these depend- 
ency needs is inhibited when goals of the mothering 
figure become the focus, and love and care are contin- 
gent upon meeting the needs of the caregiver rather 
than the infant. 

Clients with unmet dependency needs regress dur- 
ing illness and demonstrate behaviors that relate to 
this stage of development. Other clients regress to this 
level because of physical disabilities associated with 
their illness. Peplau believed that, when nurses provide 
unconditional care, they help these clients progress 
toward more mature levels of functioning. This may 
involve the role of "surrogate mother," in which the 
nurse fulfills needs for the client with the intent of 
helping him or her grow, mature, and become more 

for relief of discomfort at will, but must delay to use the 
toilet, which is considered more culturally acceptable. 
When toilet training occurs too early or is very rigid, 
or when appropriate behavior is set forth as a condition 
for love and caring, tasks associated with this stage re- 
main unfulfilled. The child feels powerless and fails to 
learn the satisfaction of pleasing others by delaying self- 
gratification in small ways. He or she may also exhibit 
rebellious behavior by failing to comply with demands 
of the mothering figure in an effort to counter the feel- 
ings of powerlessness. The child may accomplish this 
by withholding the fecal product or failing to deposit it 
in the culturally acceptable manner. 

Peplau cites Fromm (1949) in describing the follow- 
ing potential behaviors of individuals who have failed to 
complete the tasks of the second stage of development: 

• Exploitation and manipulation of others to satisfy 
their own desires because they are unable to do so 

• Suspiciousness and envy of others, directing hostil- 
ity toward others in an effort to enhance their own 

• Hoarding and withholding possessions from others; 

• Inordinate neatness and punctuality 

• Inability to relate to others through sharing of feel- 
ings, ideas, or experiences 

• Ability to vary the personality characteristics to 
those required to satisfy personal desires at any 
given time 

When nurses observe these types of behaviors in cli- 
ents, it is important to encourage full expression and 
to convey unconditional acceptance. When the client 
learns to feel safe and unconditionally accepted, he or 
she is more likely to let go of the oppositional behavior 
and advance in the developmental progression. Peplau 
(1991) stated: 

Nurses who aid patients to feel safe and secure, so 
that wants can be expressed and satisfaction eventually 
achieved, also help them to strengthen personal power 
that is needed for productive social activities, (p. 207) 

Learning to Delay Satisfaction 

Pepleu related this stage to that of toddlerhood, or the 
first step in the development of interdependent social 
relations. Psychos exually, it is compared to the anal 
stage of development, when a child learns that, because 
of cultural mores, he or she cannot empty the bowels 

Identifying Oneself 

"A concept of self develops as a product of interaction 
with adults" (Peplau, 1991, p. 211). A child learns to 
structure self-concept by observing how others interact 
with him or her. Roles and behaviors are established 
out of the child's perception of the expectations of 
others. When children perceive that adults expect them 

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Chapter 2 



to maintain more-or-less permanent roles as infants, 
they perceive themselves as helpless and dependent. 
When the perceived expectation is that the child must 
behave in a manner beyond his or her maturational 
level, the child is deprived of the fulfillment of emo- 
tional and growth needs at the lower levels of develop- 
ment. Children who are given freedom to respond to 
situations and experiences unconditionally (i.e., with 
behaviors that are appropriate to their feelings) learn 
to improve on and reconstruct behavioral responses at 
their own pace. Peplau (1991) stated: 

The ways in which adults appraise the child and the 
way he functions in relation to his experiences and 
perceptions are taken in or introjected and become 
the child's view of himself, (p. 213) 

In nursing, it is important for the nurse to recog- 
nize cues that communicate how the client feels about 
himself or herself and about the presenting medical 
problem. In the initial interaction, it is difficult for 
the nurse to perceive the "wholeness" of the client, 
for the focus is on the condition that has caused him 
or her to seek help. Likewise, it is difficult for the 
client to perceive the nurse as a "mother (or father)" 
or "somebody's wife (or husband)" or as having a life 
aside from being there to offer assistance with the 
immediate presenting problem. As the relationship 
develops, nurses must be able to recognize client 
behaviors that indicate unfulfilled needs and pro- 
vide experiences that promote growth. For example, 
the client who very proudly announces that she has 
completed activities of daily living independently and 
wants the nurse to come and inspect her room may 
still be craving the positive reinforcement that is so 
necessary at lower levels of development. 

Nurses must also be aware of the predisposing fac- 
tors that they bring to the relationship. Attitudes and 
beliefs about certain issues can have a deleterious ef- 
fect on the client and interfere not only with the thera- 
peutic relationship, but also with the client's ability for 
growth and development. For example, a nurse who 
has strong beliefs against abortion may treat a client 
who has just undergone an abortion with disapproval 
and disrespect. The nurse may respond in this manner 
without even realizing he or she is doing so. Attitudes 
and values are introjected during early development 
and can be integrated so completely as to become a 
part of the self-system. Nurses must have knowledge 
and appreciation of their own concept of self to de- 
velop the flexibility required to accept all clients as 
they are, unconditionally. Effective resolution of prob- 
lems that arise in the interdependent relationship can 

be the means for both client and nurse to reinforce 
positive personality traits and modify those more neg- 
ative views of self. 

Developing Skills in Participation 

Peplau cites Sullivan's (1953) description of the 
"juvenile" stage of personality development (ages 6 
through 9). During this stage, the child develops the 
capacity to "compromise, compete, and cooperate" with 
others. These skills are considered basic to one's ability 
to participate collaboratively with others. If a child tries 
to use the skills of an earlier level of development (e.g., 
crying, whining, or demanding), he or she may be reject- 
ed by peers of this juvenile stage. As this stage progress- 
es, children begin to view themselves through the eyes 
of their peers. Sullivan (1953) called this "consensual 
validation." Preadolescents take on a more realistic view 
of the world and a feeling of their place in it. The capac- 
ity to love others (besides the mother figure) develops 
at this time and is expressed in relation to one's self- 

Failure to develop appropriate skills at any point 
along the developmental progression results in an in- 
dividual's difficulty with participation in confronting 
the recurring problems of life. It is not the responsi- 
bility of the nurse to teach solutions to problems, but 
rather to help clients improve their problem-solving 
skills so that they may achieve their own resolution. 
This is accomplished through development of the skills 
of competition, compromise, cooperation, consensual 
validation, and love of self and others. Nurses can as- 
sist clients to develop or refine these skills by helping 
them to identify the problem, define a goal, and take 
the responsibility for performing the actions necessary 
to reach that goal. Peplau (1991) stated: 

Participation is required by a democratic society. 
When it has not been learned in earlier experiences, 
nurses have an opportunity to facilitate learning in 
the present and thus to aid in the promotion of a 
democratic society, (p. 259) 

Relevance of Peplau 's Model to Nursing 

Peplau's model provides nurses with a framework to 
interact with clients, many of whom are fixed in — or, 
because of illness, have regressed to — an earlier level of 
development. She suggests roles that nurses may assume 
to assist clients to progress, thereby achieving or resum- 
ing their appropriate developmental level. Appropriate 
developmental progression arms the individual with the 

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ability to confront the recurring problems of life. Nurses 
serve to facilitate learning of that which has not been 
learned in earlier experiences. 


■ Growth and development are unique to each indi- 
vidual and continue throughout the life span. 
Personality is defined as the combination of character, 
behavioral, temperamental, emotional, and mental 
traits that are unique to each specific individual. 
Sigmund Freud, who has been called the father of 
psychiatry, believed the basic character has been 
formed by the age of 5 . 

Freud's personality theory can be conceptualized ac- 
cording to structure and dynamics of the personal- 
ity, topography of the mind, and stages of personal- 
ity development. 

Freud's structure of the personality includes the id, 
ego, and superego. 

Freud classified all mental contents and operations 
into three categories: the conscious, the precon- 
scious, and the unconscious. 

Harry Stack Sullivan, author of the Interpersonal 
Theory of Psychiatry, believed that individual behavior 
and personality development are the direct result of 

interpersonal relationships. Major concepts include 
anxiety, satisfaction of needs, interpersonal security, and 

Erik Erikson studied the influence of social proc- 
esses on the development of the personality. 
Erikson described eight stages of the life cycle from 
birth to death. He believed that individuals strug- 
gled with developmental "crises" and that each must 
be resolved for emotional growth to occur. 
Margaret Mahler formulated a theory that de- 
scribes the separation-individuation process of the 
infant from the maternal figure (primary caregiv- 
er). Stages of development describe the progres- 
sion of the child from birth to object constancy at 
age 36 months. 

Hildegard Peplau provided a framework for "psy- 
chodynamic nursing," the interpersonal involvement 
of the nurse with a client in a given nursing situation. 
Peplau identified the nursing roles of resource per- 
son, counselor, teacher, leader, technical expert, and 

Peplau describes four psychological tasks that she 
associates with the stages of infancy and childhood 
as identified by Freud and Sullivan. 
Peplau believed that nursing is helpful when both 
the patient and the nurse grow as a result of the 
learning that occurs in the nursing situation. 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 

1. Mr. J. is a new client on the psychiatric unit. He is 35 years old. Theoretically, in which level of 
psychosocial development (according to Erikson) would you place Mr. J.? 

a. Intimacy vs. isolation 

b. Generativity vs. self-absorption 

c. Trust vs. mistrust 

d. Autonomy vs. shame and doubt 

2. Mr. J. has been diagnosed with Paranoid Schizophrenia. He refuses to eat and told the nurse he 
knew he was "being poisoned." According to Erikson 's theory, in what developmental stage would 
you place Mr. J.? 

a. Intimacy vs. isolation 

b. Generativity vs. self-absorption 

c. Trust vs. mistrust 

d. Autonomy vs. shame and doubt 

3. Janet, a psychiatric client diagnosed with Borderline Personality Disorder, has just been hospital- 
ized for threatening suicide. According to Mahler's theory, Janet did not receive the critical "emo- 
tional refueling" required during the rapprochement phase of development. What are the conse- 
quences of this deficiency? 

a. She has not yet learned to delay gratification. 

b. She does not feel guilt about wrongdoings to others. 

c. She is unable to trust others. 

d. She has internalized rage and fears of abandonment. 

4. John is on the Alcohol Treatment Unit. He walks into the dayroom where other clients are watch- 
ing a program on TV. He picks up the remote and changes the channel and says, "That's a stupid 
program! I want to watch something else!" In what stage of development is John fixed according to 
Sullivan's interpersonal theory? 

a. Juvenile because he is learning to form satisfactory peer relationships. 

b. Childhood because he has not learned to delay gratification. 

c. Early adolescence because he is struggling to form an identity. 

d. Late adolescence because he is working to develop a lasting relationship. 

5. Adam has Antisocial Personality Disorder. He says to the nurse, "I'm not crazy. I'm just fun-loving. 
I believe in looking out for myself. Who cares what anyone thinks? If it feels good, do it!" Which of 
the following describes the psychoanalytical structure of Adam's personality? 

a. Weak id, strong ego, weak superego 

b. Strong id, weak ego, weak superego 

c. Weak id, weak ego, punitive superego 

d. Strong id, weak ego, punitive superego 

6. Larry, who has Antisocial Personality Disorder, feels no guilt about violating the rights of others 
He does as he pleases without thought to possible consequences. In which of Peplau's stages of 
development would you place Larry? 

a. Learning to count on others 

b. Learning to delay gratification 

c. Identifying oneself 

d. Developing skills in participation 



2338_Ch02_016-032.indd 31 

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7. Danny has been diagnosed with Paranoid Schizophrenia. On the unit he appears very anxious, 
paces back and forth, and darts his head from side to side in a continuous scanning of the area. He 
has refused to eat, making some barely audible comment related to "being poisoned." In planning 
care for Danny, which of the following would be the primary focus for nursing? 

a. To decrease anxiety and develop trust 

b. To set limits on his behavior 

c. To ensure that he gets to group therapy 

d. To attend to his hygiene needs 

8. The nurse has just admitted Nancy to the psychiatric unit. The psychiatrist has diagnosed Nancy 
with Major Depression. The nurse says to Nancy, "Please tell me what it was like when you were 
growing up." Which nursing role described by Peplau is the nurse fulfilling in this instance? 

a. Surrogate 

b. Resource person 

c. Counselor 

d. Technical expert 

9. The nurse has just admitted Nancy to the psychiatric unit. The psychiatrist has diagnosed Nancy 
with Major Depression. The nurse says to Nancy, "What questions do you have about being here 
on the unit?" Which nursing role described by Peplau is the nurse fulfilling in this instance? 

a. Resource person 

b. Counselor 

c. Surrogate 

d. Technical expert 

10. The nurse has just admitted Nancy to the psychiatric unit. The psychiatrist has diagnosed Nancy 
with Major Depression. The nurse says to Nancy, "Some changes will have to be made in your 
behavior. I care about what happens to you." Which nursing role described by Peplau is the nurse 
fulfilling in this instance? 

a. Counselor 

b. Surrogate 

c. Technical expert 

d. Resource person 




American Psychiatric Association (APA). (2000). Diagnostic and 
statistical manual of mental disorders (4th ed.). Text revision. 
Washington, DC: American Psychiatric Publishing. 

Marmer, S.S. (2003). Theories of the mind and psychopathology. In 
R.E. Hales & S.C. Yudofsky (Eds.), Textbook of clinical psychiatry 
(4th ed.). Washington, DC: American Psychiatric Publishing. 

Murray, R.B., Zentner, J.P., & Yakimo, R. (2008). Health promotion 
strategies through the life span (8th ed.). Upper Saddle River, NJ: 
Prentice Hall. 

Peplau, H.E. (1991). Interpersonal relations in nursing. New York: 


Chess, S., & Thomas, A. (1986). Temperament in clinical practice. 

New York: The Guilford Press. 
Erikson, E. (1963). Childhood and society (2nd ed.). New York: 

WW Norton. 
Freud, S. (1961). The ego and the id. Standard edition of the complete 

psychological works of Freud (Vol XIX). London: Hogarth Press. 

Fromm, E. (1949). Man for himself. New York: Farrar & Rinehart. 
Mahler, M., Pine, F, & Bergman, A. (1975). The psychological birth of 

the human infant. New York: Basic Books. 
Sullivan, H.S. (1953). The interpersonal theory of psychiatry. 

New York: WW Norton. 

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H A P T E R 

Biological Implications 










axon neuroendocrine system 

cell body neurons 

dendrites synapse 

limbic system 






After reading this chapter, the student will be able to: 

1. Identify gross anatomical structures of the 
brain and describe their functions. 
Discuss the physiology of neurotransmis- 
sion within the central nervous system. 
Describe the role of neurotransmitters in 
human behavior. 

Discuss the association of endocrine func- 
tioning to the development of psychiatric 

Discuss the correlation of alteration in 
brain function to various psychiatric 





6. Identify various diagnostic procedures 
used to detect alteration in biological 
functioning that may be contributing to 
psychiatric disorders. 

7. Discuss historical perspectives related to 

8. Describe the physiological mechanism by 
which various psychotropic medications 
exert their effects. 

9. Discuss the implications of psychobio- 
logical concepts to the practice of 
psychiatric/mental health nursing. 


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Please read the chapter and answer the following questions. 

1. A dramatic reduction in which neuro- 
transmitter is most closely associated 
with Alzheimer's disease? 

2. Anorexia nervosa has been associated 
with a primary dysfunction of which 
structure of the brain? 

3. Many psychotropics work by blocking the 
reuptake of neurotransmitters. Describe 
the process of reuptake. 


In recent years, a greater emphasis has been placed on 
the study of the organic basis for psychiatric illness. 
This "neuroscientific revolution" began in earnest when 
the 101st legislature of the United States designated the 
1990s as the "decade of the brain." With this legislation 
came the challenge for studying the biological basis of 
behavior. Several mental illnesses are now being consid- 
ered as physical disorders that are the result of malfunc- 
tions and/or malformations of the brain. 

This is not to imply that psychosocial and sociocul- 
tural influences are totally discounted. The systems of 
biology, psychology, and sociology are not mutually 
exclusive — they are interacting systems. This is clearly 
indicated by the fact that individuals experience bio- 
logical changes in response to various environmental 
events. Indeed, each of these disciplines may at vari- 
ous times be most appropriate for explaining behavio- 
ral phenomena. This chapter presents an overview of 
neurophysiological, neurochemical, and endocrine in- 
fluences on psychiatric illness. Various diagnostic pro- 
cedures used to detect alterations in biological function 
that may contribute to psychiatric illness are identified. 
A historical perspective related to psychopharmacol- 
ogy is presented, and the physiological mechanism 
by which various psychotropic medications exert their 
effects is described. A discussion of the implications for 
nursing is included. 



The study of the biological foundations of cogni 
tive, emotional, and behavioral processes. 


The Nervous System 

The nervous system is composed of two major divisions: 
the central nervous system (CNS) and the peripheral 
nervous system (PNS). An outline of the components of 
these two divisions is presented in Box 3-1. A discussion 
of the primary functions of these components follows. 

The Central Nervous System 

The Brain 

The brain has three main divisions that are subdivided 
into six major parts. The forebrain is made up of the 
cerebrum and diencephalon. The midbrain is the mes- 
encephalon. The pons, medulla, and cerebellum make 
up the hindbrain. These six structures are discussed in- 
dividually. Diagrams of these structures are presented 
in Figures 3-1, 3-2, and 3-3. 

Cerebrum. The cerebrum is composed of two hemi- 
spheres separated by a deep groove that houses a band 
of 200 million neurons (nerve cells) called the cor- 
pus callosum. The outer shell is called the cortex. It is 
extensively folded and consists of billions of neurons. 
The left hemisphere appears to be dominant in most 
people. It controls speech, comprehension, rational- 
ity, and logic. The right hemisphere is nondominant 
in most people. Sometimes called the "creative" brain, 
the right hemisphere is associated with affect, behav- 
ior, and spatial perceptual functions. Each hemisphere 
is divided into four lobes. 

• Frontal lobes: The frontal lobes control voluntary 
body movement, including movements that permit 
speaking, thinking, and judgment formation. The 
frontal lobe may also play a role in the emotional 
experience, as evidenced by changes in mood and 

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jj Box 3-1 Components of the Nervous 

I. Central nervous system 

A. Brain 

1. Forebrain 

a. Cerebrum 

i. Frontal lobes 
ii. Parietal lobes 
iii. Temporal lobes 
iv. Occipital lobes 

b. Diencephalon 

i. Thalamus 
ii. Hypothalamus 
iii. Limbic system 

2. Midbrain 

a. Mesencephalon 

3. Hindbrain 

a. Pons 

b. Medulla 

c. Cerebellum 

B. Nerve tissue 

1. Neurons 

2. Synapses 

3. Neurotransmitters 

C. Spinal cord 

1 . Fiber tracts 

2 . Spinal nerves 

II. Peripheral nervous system 

A. Afferent system 

1. Sensory neurons 

a. Somatic 

b. Visceral 

B. Efferent system 

1. Somatic nervous system 

a. Somatic motor neurons 

2 . Autonomic nervous system 

a. Sympathetic nervous system 
i. Visceral motor neurons 

b. Parasympathetic nervous system 
i. Visceral motor neurons 

character after damage to this area. The altera- 
tions include fear, aggressiveness, depression, rage, 
euphoria, irritability, and apathy, and are likely 
related to a frontal lobe connection to the limbic 

Parietal lobes: The parietal lobes control percep- 
tion and interpretation of most sensory information 
(including touch, pain, taste, and body position). 
Language interpretation is associated with the left 
hemisphere of the parietal lobe. 
Temporal lobes: The upper anterior temporal lobe 
is concerned with auditory functions, while the lower 
part is dedicated to short-term memory. The sense of 
smell has a connection to the temporal lobes, as the 
impulses carried by the olfactory nerves end in this 

area of the brain (Scanlon & Sanders, 2011). The 
temporal lobes also play a role in the expression 
of emotions through an interconnection with the 
limbic system. The left temporal lobe, along with 
the left parietal lobe, is involved in language inter- 

• Occipital lobes: The occipital lobes are the primary 
area of visual reception and interpretation. Visual 
perception, which gives individuals the ability to 
judge spatial relationships such as distance and to 
see in three dimensions, is also processed in this area 
(Scanlon & Sanders, 2011). Language interpretation 
is influenced by the occipital lobes through an as- 
sociation with the visual experience. 

Diencephalon. The diencephalon connects the cer- 
ebrum with lower brain structures. Its major structures 
include the thalamus, hypothalamus, and limbic system. 

• Thalamus: The thalamus integrates all sensory in- 
put (except smell) on its way to the cortex. The tha- 
lamus also has some involvement with emotions and 

• Hypothalamus: The hypothalamus regulates the 
anterior and posterior lobes of the pituitary gland. It 
exerts control over the actions of the autonomic nerv- 
ous system, and regulates appetite and temperature. 

• Limbic system: The limbic system consists of 
medially placed cortical and subcortical structures 
and the fiber tracts connecting them with one an- 
other and with the hypothalamus. These struc- 
tures include the hippocampus, mammillary body, 
amygdala, olfactory tract, hypothalamus, cingulate 
gyrus, septum pellucidum, thalamus, and fornix. 
The limbic system, which is sometimes called the 
"emotional brain," is associated with fear and anxi- 
ety; anger and aggression; love, joy, and hope; and 
sexuality and social behavior. 

Mesencephalon. Structures of major importance in 
the mesencephalon, or midbrain, include nuclei and 
fiber tracts. They extend from the pons to the hypotha- 
lamus and are responsible for the integration of various 
reflexes, including visual reflexes (e.g., automatically 
turning away from a dangerous object when it comes 
into view), auditory reflexes (e.g., automatically turn- 
ing toward a sound that is heard), and righting reflexes 
(e.g., automatically keeping the head upright and main- 
taining balance) (Scanlon & Sanders, 2011). 

Pons. The pons is the bulbous structure that lies be- 
tween the midbrain and the medulla (see Fig. 3-2). It 
is composed of large bundles of fibers and forms a ma- 
jor connection between the cerebellum and the brain- 
stem. It also contains the central connections of cranial 

2338_Ch03_033-057.indd 35 

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Motor area 

Premotor area 

General sensory area 

Sensory association 

Parietal lobe 

Occipital lobe 

Visual association 

Visual area 


Temporal lobe 

FIGURE 3—1 The human brain: cerebral lobes, cerebellum, and brainstem. 

Corpus callosum 

Frontal lobe 

^ .2 
I '1 

^s Oh 

*2 q Choroid plexus in 
'g j third ventricle 

- -a 
U - 


Optic nerve 


Pituitary gland 

Parietal lobe 

Occipital lobe 

Choroid plexus in 
fourth ventricle 

Temporal lobe 

FIGURE 3-2 The human brain: Midsagittal surface. 

2338_Ch03_033-057.indd 36 

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Chapter 3 









FIGURE 3-3 Structures of the limbic system. 


^ 3 


W © 


Hippocampus q | 

B 1 

nerves V through VIII and centers for respiration and 
skeletal muscle tone. 

Medulla. The medulla provides a pathway for all as- 
cending and descending fiber tracts. It contains vital 
centers that regulate heart rate, blood pressure, and 
respiration, and reflex centers for swallowing, sneezing, 
coughing, and vomiting (Scanlon & Sanders, 2011). It 
also contains nuclei for cranial nerves IX through XII. 
The medulla, pons, and midbrain form the structure 
known as the brainstem. These structures are identi- 
fied in Figure 3-2. 

Cerebellum. The cerebellum is separated from the 
brainstem by the fourth ventricle, but it has connec- 
tions to the brainstem through bundles of fiber tracts. 
It is situated just below the occipital lobes of the cer- 
ebrum (see Figs. 3-1 and 3-2). The functions of the 
cerebellum are concerned with involuntary movement, 

such as muscular tone and coordination and the main- 
tenance of posture and equilibrium. 

Nerve Tissue 

Neurons. The tissue of the CNS consists of nerve 
cells called neurons that generate and transmit elec- 
trochemical impulses. The structure of a neuron is 
composed of a cell body, an axon, and dendrites. The 

cell body contains the nucleus and is essential for the 
continued life of the neuron. The dendrites are proc- 
esses that transmit impulses toward the cell body, and 
the axon transmits impulses away from the cell body. 
Cells called afferent (or sensory) neurons carry impulses 
from the periphery to the CNS, where they are inter- 
preted into various sensations. The efferent (or motor) 
neurons carry impulses from the CNS to the muscles 

2338_Ch03_033-057.indd 37 

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and glands of the periphery. Cells of a third type, called 
interneurons, exist entirely within the CNS and com- 
prise 99 percent of all nerve cells. They may carry only 
sensory or motor impulses, or they may serve as inte- 
grators in the pathways between afferent and efferent 
neurons. They account in large part for thinking, feel- 
ings, learning, language, and memory. 

Synapses. Some messages may be processed through 
only a few neurons, while others may require thou- 
sands of neuronal connections. The neurons that 
transmit the impulses do not actually touch each other. 
The junction between two neurons is called a synapse. 
The small space between the axon terminals of one 
neuron and the cell body or dendrites of another is 
called the synaptic cleft. Neurons conducting impulses 
toward the synapse are called presynaptic neurons and 
those conducting impulses away are called postsynaptic 
neurons (Fig. 3-4). 


Chemicals called neurotransmitters are stored in the 
axon terminals of presynaptic neurons. Electrical im- 
pulses cause the release of these chemicals into the 




A chemical that is stored in the axon terminals 
of the presynaptic neuron. An electrical impulse 
through the neuron stimulates the release of the 
neurotransmitter into the synaptic cleft, which in 
turn determines whether another electrical impulse 
is generated. 


Molecules situated on the cell membrane that are 
binding sites for neurotransmitters. 

synaptic cleft. The neurotransmitter combines with 
receptor sites on the postsynaptic neuron, resulting in 
a determination of whether another electrical impulse 
is generated (see Fig. 3-4). 

Neurotransmitters are responsible for essential 
functions in the role of human emotion and behav- 
ior. They are also the target for the mechanism of 
action of many of the psychotropic medications. 

Vesicles of neurotransmitter 

Receptor site 

Axon of presynaptic 


c2 W 




Dendrite of 





3-4 Impulse transmission at a synapse. The arrow indicates the direction of the electrical impulse. 

2338_Ch03_033-057.indd 38 

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After a neurotransmitter has performed its function in 
the synaptic cleft, it either returns to the vesicles 
in the axon terminals to be stored and used again, 
or it is inactivated and dissolved by enzymes. The 
process of being stored for reuse is called reuptake, 
a function that holds significance for understand- 
ing the mechanism of action of certain psychotropic 

Many neurotransmitters exist within the central and 
peripheral nervous systems, but only a limited number 
have implications for psychiatry. Major categories in- 
clude the cholinergics, monoamines, amino acids, and 


Acetylcholine. Acetylcholine was the first chemical 
to be identified and proven as a neurotransmitter. 

• Location: Acetylcholine is a major effector chemical 
within the autonomic nervous system (ANS), produc- 
ing activity at all sympathetic and parasympathetic 
presynaptic nerve terminals and all parasympathetic 
postsynaptic nerve terminals. It is highly significant 
in the neurotransmission that occurs at the junctions 
of nerve and muscles. In the CNS, acetylcholine neu- 
rons innervate the cerebral cortex, hippocampus, and 
limbic structures. The pathways are especially dense 
through the area of the basal ganglia in the brain. 

• Functions: Acetylcholine is implicated in sleep, 
arousal, pain perception, the modulation and coor- 
dination of movement, and memory acquisition and 

• Possible implications for mental illness: Cholin- 
ergic mechanisms may have some role in certain 
disorders of motor behavior and memory, such as 
Parkinson's, Huntington's, and Alzheimer's diseases. 
Increased levels of acetylcholine have been associ- 
ated with depression. 


Norepinephrine. Norepinephrine is the neurotrans- 
mitter associated with the "fight or flight" syndrome of 
symptoms that occurs in response to stress. 

• Location: Norepinephrine is found in the ANS at 
the sympathetic postsynaptic nerve terminals. In 
the CNS, norepinephrine pathways originate in 
the pons and medulla and innervate the thalamus, 
dorsal hypothalamus, limbic system, hippocampus, 
cerebellum, and cerebral cortex. 

• Functions: Norepinephrine may have a role in the 
regulation of mood, in cognition and perception, 

in cardiovascular functioning, and in sleep and 

• Possible implications for mental illness: The 

mechanism of norephinephrine transmission has 
been implicated in certain mood disorders such 
as depression and mania, in anxiety states, and in 
schizophrenia (Sadock & Sadock, 2007). Levels of 
the neurotransmitter are thought to be decreased 
in depression and increased in mania, anxiety states, 
and in schizophrenia. 

Dopamine. Dopamine is derived from the amino acid 
tyrosine and may play a role in physical activation of 
the body. 

• Location: Dopamine pathways arise from the mid- 
brain and hypothalamus and terminate in the frontal 
cortex, limbic system, basal ganglia, and thalamus. 
Dopamine neurons in the hypothalamus innervate 
the posterior pituitary and those from the posterior 
hypothalamus project to the spinal cord. 

• Functions: Dopamine is involved in the regulation 
of movements and coordination, emotions, volun- 
tary decision-making ability, and because of its in- 
fluence on the pituitary gland, it inhibits the release 
of prolactin (Sadock & Sadock, 2007). 

• Possible implications for mental illness: Decreased 
levels of dopamine have been implicated in the etiol- 
ogy of Parkinson's disease and depression (Sadock & 
Sadock, 2007). Increased levels of dopamine are asso- 
ciated with mania (Joska & Stein, 2008) and schizo- 
phrenia (Minzenberg, Yoon, & Carter, 2008). 

Serotonin. Serotonin is derived from the dietary 
amino acid tryptophan. The antidepressants called se- 
lective serotonin reuptake inhibitors (SSRIs) block the 
reuptake of this neurotransmitter to increase levels in 
the brain. 

• Location: Serotonin pathways originate from cell 
bodies located in the pons and medulla, and project 
to areas including the hypothalamus, thalamus, limbic 
system, cerebral cortex, cerebellum, and spinal cord. 
Serotonin that is not returned to be stored in the 
axon terminal vesicles is catabolized by the enzyme 
monoamine oxidase. 

• Functions: Serotonin may play a role in sleep and 
arousal, libido, appetite, mood, aggression, and pain 

• Possible implications for mental illness: Increased 
levels of serotonin have been implicated in schizo- 
phrenia and anxiety states (Sadock & Sadock, 2007). 
Decreased levels of the neurotransmitter have been 
associated with depression (Joska & Stein, 2008). 

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Histamine. The role of histamine in mediating al- 
lergic and inflammatory reactions has been well docu- 
mented. Its role in the CNS as a neurotransmitter has 
only recently been confirmed, and only limited infor- 
mation is available. 

• Location: The highest concentrations of histamine are 
found within various regions of the hypothalamus. 

• Function: The exact processes mediated by hista- 
mine within the CNS are unclear. 

• Possible implications for mental illness: Some 
data suggest that histamine may play a role in de- 
pressive illness. 

Amino Acids 

Gamma Aminobutyric Acid (GABA). GABA is asso- 
ciated with short inhibitory interneurons, although 
some long- axon pathways within the brain have now 
been identified. 

• Location: There is widespread distribution of 
GABA in the central nervous system, with high 
concentrations in the hypothalamus, hippocampus, 
cortex, cerebellum, and basal ganglia of the brain; 
in the gray matter of the dorsal horn of the spinal 
cord; and in the retina. 

• Functions: GABA interrupts the progression of the 
electrical impulse at the synaptic junction, produc- 
ing a significant slowdown of body activity. 

• Possible implications for mental illness: Decreased 
levels of GABA have been implicated in the etiology 
of anxiety disorders, movement disorders such as 
Huntington's disease, and various forms of epilepsy. 

Glycine. Glycine is also considered to be an inhibi- 
tory amino acid. 

• Location: Highest concentrations of glycine in the 
CNS are found in the spinal cord and brainstem. 

• Functions: Glycine appears to be involved in 
recurrent inhibition of motor neurons within the 
spinal cord and is possibly involved in the regula- 
tion of spinal and brainstem reflexes. 

• Possible implications for mental illness: De- 
creased levels of glycine have been implicated in the 
pathogenesis of certain types of spastic disorders. 
Toxic accumulation of the neurotransmitter in the 
brain and cerebrospinal fluid can result in "glycine 
encephalopathy" (Hamosh, 2005). 

Glutamate. This neurotransmitter appears to be pri- 
marily excitatory in nature. 

• Location: Glutamate is found in the pyramidal cells 
of the cortex, cerebellum, and the primary sensory 

afferent systems. It is also found in the hippocam- 
pus, thalamus, hypothalamus, and spinal cord. 

• Functions: Glutamate functions in the relay of sen- 
sory information and in the regulation of various 
motor and spinal reflexes. 

• Possible implications for mental illness: In- 
creased receptor activity has been implicated in the 
etiology of certain neurodegenerative disorders, 
such as Parkinson's disease. Decreased receptor ac- 
tivity can induce psychotic behavior. 


Endorphins and Enkephalins. These neurotransmit- 
ters are sometimes called opioid peptides. 

• Location: They have been found in various con- 
centrations in the hypothalamus, thalamus, limbic 
structures, midbrain, and brainstem. Enkephalins 
are also found in the gastrointestinal (GI) tract. 

• Function: With their natural morphine-like prop- 
erties, they are thought to have a role in pain mod- 

• Possible implications for mental illness: Modula- 
tion of dopamine activity by opioid peptides may in- 
dicate some link to the symptoms of schizophrenia. 

Substance P. Substance P was the first neuropeptide 
to be discovered. 

• Location: Substance P is present in high concen- 
trations in the hypothalamus, limbic structures, 
midbrain, and brainstem, and is also found in the 
thalamus, basal ganglia, and spinal cord. 

• Functions: Substance P is thought to play a role in 
sensory transmission, particularly in the regulation 
of pain. 

• Possible implications for mental illness: Decreased 
concentrations have been found in the substantia ni- 
gra of the basal ganglia of clients with Huntington's 

Somatostatin. Somatostatin is also called the growth 
hormone-inhibiting hormone. 

• Location: Somatostatin is found in the cerebral 
cortex, hippocampus, thalamus, basal ganglia, brain- 
stem, and spinal cord. 

• Functions: In its function as a neurotransmitter, 
somatostatin exerts both stimulatory and inhibitory 
effects. Depending on the part of the brain being 
affected, it has been shown to stimulate dopamine, 
serotonin, norepinephrine, and acetylcholine and to 
inhibit norepinephrine, histamine, and glutamate. 
It also acts as a neuromodulator for serotonin in 
the hypothalamus, thereby regulating its release 

2338_Ch03_033-057.indd 40 

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(i.e., determining whether it is stimulated or inhib- 
ited). It is possible that somatostatin may serve this 
function for other neurotransmitters as well. 
• Possible implications for mental illness: High 
concentrations of somatostatin have been reported in 
brain specimens of clients with Huntington's disease; 
low concentrations have been reported in clients with 
Alzheimer's disease. 

Spinal Cord 

The second major component of the CNS is the spinal 
cord. It transmits impulses to and from the brain and 
is the integrating center for the spinal cord reflexes 
(Scanlon & Sanders, 2011). 

Fiber Tracts. A cross section of the spinal cord re- 
veals an area of gray matter in the central part that 
is made up of the cell bodies of motor neurons and 
interneurons. Around the external part of the cord 
is an area of white matter, so called because the 
fibers that make up the area are sheathed in a white 
lipid substance called myelin. Ascending spinal tracts 
carry sensory impulses to the brain, and descending 
tracts carry motor impulses from the brain to the pe- 
riphery. The center of the spinal cord contains cer- 
ebrospinal fluid and is continuous with the ventricles 
in the brain. 

Spinal Nerves. Thirty-one pairs of nerves emerge 
from the spinal cord. They do not have names, but 
are identified by the level of the vertebrae from which 
they arise. In general, the cervical nerves supply the 
upper portion of the body, including the diaphragm. 
Most of the thoracic nerves supply the trunk of the 
body, and the lumbar and sacral nerves supply the 
hips, pelvic cavity, and legs (Scanlon & Sanders, 201 1). 
Damage to the spinal cord results in loss of, or altera- 
tion in, function to the part of the body innervated by 
the spinal nerves that arise from the injured area of 
the cord. Regeneration of damaged neurons depends 
on extent and severity of the injury and expedience in 
receiving treatment. 

The Peripheral Nervous System 

The PNS is composed of the nerve processes that con- 
nect the CNS (brain and spinal cord) with the recep- 
tors, muscles, and glands in the periphery of the body. 

The Afferent System 

Afferent, or sensory, neurons convey information from 
receptors in the periphery to the CNS (Scanlon & 
Sanders, 2011). Various receptors respond to specific 

stimuli that generate neuronal impulses to the CNS. 
For example, receptors in the eye respond to light 
stimuli, receptors in the skin respond to touch or pain 
stimuli, and receptors in the ear respond to sound 
stimuli. Once activated, receptors generate an impulse 
to the CNS for interpretation of the sensation. Sen- 
sory neurons from external areas of the body, such 
as skin, skeletal muscles, and joints, are called somat- 
ic; those from receptors in internal organs are called 
visceral (Scanlon & Sanders, 201 1). 

The Efferent System 

Efferent, or motor, neurons carry information from 
the CNS to peripheral areas of the body. This includes 
skeletal muscles, smooth and cardiac muscles, and 

Somatic Nervous System. The somatic nervous sys- 
tem consists of fibers that go from the CNS (either 
brain or spinal cord) to skeletal muscle cells. The ex- 
citation of these neurons, sometimes called somatic 
motor neurons, always leads to contraction of a skeletal 

Autonomic Nervous System. Efferent neurons of the 
ANS innervate smooth muscles, cardiac muscles, and 
glands. These neurons are sometimes called visceral 
motor neurons. The ANS is further divided into sym- 
pathetic and parasympathetic components, which often 
function in opposition to each other. Many glands 
and muscles have dual innervation; that is, they are 
stimulated by both sympathetic and parasympathetic 
fibers. In these instances, when the activity of one 
system is enhanced, the activity of the other is sup- 
pressed (Fig. 3-5). 

• Sympathetic nervous system: The sympathetic 
nervous system becomes the dominant compo- 
nent during stressful situations. Activation of 
the sympathetic nervous system results in the 
"fight or flight" response that was described in 
Chapter 1. Examples of this response include 
increased cardiac and respiratory activity and a 
decrease in GI functioning. Neurotransmitters 
involved in impulse transmission within the sym- 
pathetic nervous system include acetylcholine and 

• Parasympathetic nervous system: The parasympa- 
thetic nervous system is dominant in the nonstress- 
ful or relaxed state. Parasympathetic dominance 
promotes efficient GI functioning and maintains 
heart and respiration at resting rates. The neuro- 
transmitter found in the parasympathetic nervous 
system is acetylcholine. 

2338_Ch03_033-057.indd 41 

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FIGURE 3-5 The autonomic nervous system. 

2338_Ch03_033-057.indd 42 

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The Neuroendocrine System 

The neuroendocrine system deals with the inter- 
action between the nervous and endocrine systems 
and the hormones that react to stimulation from the 
nerve cells. 

The Pituitary Gland 

The pituitary gland is only about the size of a pea, 
but despite its size and because of the powerful 

control it exerts over endocrine functioning in hu- 
mans, it is sometimes called the "master gland." Many 
of the hormones subject to hypothalamus -pituitary 
regulation may have implications for behavioral func- 
tioning. Discussion of these hormones is summarized 
in Table 3-1. 

The pituitary gland has two major lobes — the 
anterior lobe (also called the adenohypophysis) and 
the posterior lobe (also called the neurohypophysis). 
The pituitary gland is under the direct control of 
the hypothalamus. 

Table 3-1 

Hormones of the Neuroendocrine System 

Possible Behavioral 

Location and 

Correlation to Altered 


Stimulation of Release 

Target Organ 





Growth hormone 






Posterior pituitary; release 
stimulated by dehydra- 
tion, pain, stress 

Posterior pituitary; release 
stimulated by end of 
pregnancy, stress, sexual 

Anterior pituitary; release 
stimulated by growth 
hormone-releasing hor- 
mone from hypothalamus 

Anterior pituitary; release 
stimulated by thyrotropin- 
releasing hormone from 

Anterior pituitary; 

release stimulated by 


hormone from 

Anterior pituitary; release 

stimulated by prolactin- 

releasing hormone from 

Anterior pituitary; 

release stimulated by 


hormone from 


Anterior pituitary; release 
stimulated by onset of 

Kidney (causes 

Uterus; breasts 

Bones and tissues 

Thyroid gland 

Adrenal cortex 


Ovaries and testes 

Pineal gland 

Conservation of body 
water and main- 
tenance of blood 

Contraction of the 
uterus for labor; re- 
lease of breast milk 

Growth in children; 
protein synthesis in 

Stimulation of secretion 
of thyroid hor- 
mones needed for 
metabolism of food 
and regulation of 

Stimulation of secre- 
tion of Cortisol, 
which plays a role in 
response to stress 

Stimulation of milk 

Stimulation of secre- 
tion of estrogen, 
progesterone, and 
testosterone; role in 
ovulation and sperm 

Stimulation of secretion 
of melatonin 

Polydipsia; altered pain 
response; modified sleep 

May play role in stress 
response by stimulation 

Anorexia nervosa 

Increased levels: insomnia, 
anxiety, emotional lability 

Decreased levels: 
depression, fatigue 

Increased levels: mood 
disorders, psychosis 

Decreased levels: depres- 
sion, apathy, fatigue 

Increased levels: depression, 
anxiety, decreased libido, 

Decreased levels: de- 
pression and anorexia 
nervosa; Increased tes- 
tosterone: increased 
sexual behavior and 

Increased levels: 

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Ne u rohyp ophysis 

The hypothalamus has direct control over the posterior 
pituitary through efferent neural pathways. Two hor- 
mones are found in the posterior pituitary: vasopressin 
or antidiuretic hormone (ADH) and oxytocin. They 
are actually produced by the hypothalamus and stored 
in the posterior pituitary. Their release is mediated by 
neural impulses from the hypothalamus (Fig. 3-6). 

Antidiuretic Hormone. The main function of ADH 
is to conserve body water and maintain normal blood 
pressure. The release of ADH is stimulated by pain, 
emotional stress, dehydration, increased plasma con- 
centration, or decreased blood volume. An alteration 
in the secretion of this hormone may be a factor in 
the polydipsia observed in about 10 to 15 percent of 
hospitalized psychiatric patients. Other factors corre- 
lated with this behavior include adverse effects of psy- 
chotropic medications and features of the behavioral 
disorder itself. ADH also may play a role in learning 
and memory, in alteration of the pain response, and in 
the modification of sleep patterns. 

Oxytocin. Oxytocin stimulates contraction of the 
uterus at the end of pregnancy and stimulates release 
of milk from the mammary glands (Scanlon & Sanders, 
201 1). It is also released in response to stress and dur- 
ing sexual arousal. Its role in behavioral functioning is 
unclear, although it is possible that oxytocin may act 

in certain situations to stimulate the release of adreno- 
corticotropic hormone (ACTH), thereby playing a key 
role in the overall hormonal response to stress. 

Aden ohyp ophysis 

The hypothalamus produces releasing hormones that 
pass through capillaries and veins of the hypophy- 
seal portal system to capillaries in the anterior pi- 
tuitary, where they stimulate secretion of specialized 
hormones. This pathway is presented in Figure 3-6. 
The hormones of the anterior pituitary gland regulate 
multiple body functions and include growth hormone 
(GH), thyroid-stimulating hormone (TSH), ACTH, 
prolactin, gonadotropin-stimulating hormone, and 
melanocyte-stimulating hormone (MSH). Most of 
these hormones are regulated by a negative feedback 
mechanism. Once the hormone has exerted its effects, 
the information is "fed back" to the anterior pituitary, 
which inhibits the release and ultimately decreases the 
effects of the stimulating hormones. 

Growth Hormone. The release of GH, also called so- 
matotropin, is stimulated by growth hormone-releasing 
hormone (GHRH) from the hypothalamus. Its release 
is inhibited by growth hormone -inhibiting hormone 
(GHIH), or somatostatin, also from the hypothalamus. 
It is responsible for growth in children and continued 
protein synthesis throughout life. During periods of 


Releasing hormones 
Capillaries in hypothalamus 

Hypophyseal portal veins 

Capillaries in 
anterior pituitary 

Hormones of 
anterior pituitary 

Lateral hypophyseal vein 



Optic chiasma 


Hypothalamic-hypophyseal tract 

Posterior pituitary 


Inferior hypophyseal 

Hormones of 

n^^T" ■■'■ ■ - posterior 

\ pituitary 

Posterior lobe vein 

FIGURE 3-6 Hypothalamic regulation of pituitary hormones. (A) Releasing hormones of the hypothalamus circulate directly to the 
anterior pituitary and influence its secretions. (B) Posterior pituitary stores hormones produced in the hypothalamus. 

2338_Ch03_033-057.indd 44 

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fasting, it stimulates the release of fat from the adipose 
tissue to be used for increased energy. The release of 
GHIH is stimulated in response to periods of hyperg- 
lycemia. GHRH is stimulated in response to hypogly- 
cemia and to stressful situations. During prolonged 
stress, GH has a direct effect on protein, carbohydrate, 
and lipid metabolism, resulting in increased serum 
glucose and free fatty acids to be used for increased 
energy. There has been some indication of a possible 
correlation between abnormal secretion of growth 
hormone and anorexia nervosa. 

Thyroid-Stimulating Hormone. Thyrotropin-releasing 
hormone from the hypothalamus stimulates the release 
of TSH, or thyrotropin, from the anterior pituitary. 
TSH stimulates the thyroid gland to secrete triiodothy- 
ronine (T 3 ) and thyroxine (T 4 ). Thyroid hormones are 
integral to the metabolism of food and the regulation 
of temperature. 

A correlation between thyroid dysfunction and al- 
tered behavioral functioning has been noted. Hyperthy- 
roidism is characterized by irritability, insomnia, anxiety, 
restlessness, weight loss, and emotional lability. In some 
instances, serious psychiatric symptoms, such as impair- 
ments in memory and orientation, manic excitement, 
delusions, and hallucinations, are evident (Sadock & 
Sadock, 2007). Fatigue, weight gain, cold intolerance, 
depression, hypomania, slowed thinking, and delirium 
have been associated with hypothyroidism. Studies 
have correlated various forms of thyroid dysfunction 
with mood disorders, anxiety, eating disorders, schizo- 
phrenia, and dementia. 

Adrenocorticotropic Hormone. Corticotropin- 
releasing hormone (CRH) from the hypothalamus 
stimulates the release of ACTH from the anterior 
pituitary. ACTH stimulates the adrenal cortex to se- 
crete Cortisol. The role of Cortisol in human behavior 
is not well understood, although it seems to be secret- 
ed under stressful situations. Disorders of the adrenal 
cortex can result in hyposecretion or hypersecretion 
of Cortisol. 

Addison's disease is the result of hyposecretion of the 
hormones of the adrenal cortex. Behavioral symptoms 
of hyposecretion include mood changes with apathy, 
social withdrawal, impaired sleep, decreased concen- 
tration, and fatigue. Hypersecretion of Cortisol results 
in Cushing's disease and is associated with behaviors 
that include depression, mania, psychosis, and suicidal 
ideation. Cognitive impairments also have been com- 
monly observed. 

Prolactin. Serum prolactin levels are regulated by 
prolactin-releasing hormone and prolactin-inhibiting 
hormone from the hypothalamus. Prolactin stimulates 

milk production by the mammary glands in the presence 
of high levels of estrogen and progesterone during preg- 
nancy. Behavioral symptoms associated with hypersecre- 
tion of prolactin include depression, decreased libido, 
stress intolerance, anxiety, and increased irritability. 

Gonadotropic Hormones. The gonadotropic hor- 
mones are so called because they produce an effect on 
the gonads — the ovaries and the testes. The gonado- 
tropins include follicle-stimulating hormone (FSH) 
and luteinizing hormone (LH), and their release from 
the anterior pituitary is stimulated by gonadotropin- 
releasing hormone (GnRH) from the hypothalamus. 
In women, FSH initiates maturation of ovarian follicles 
into the ova and stimulates their secretion of estrogen. 
LH is responsible for ovulation and the secretion of 
progesterone from the corpus luteum. In men, FSH 
initiates sperm production in the testes, and LH in- 
creases secretion of testosterone by the interstitial cells 
of the testes (Scanlon & Sanders, 2011). The gonado- 
tropins are regulated by a negative feedback of gonadal 
hormones at the hypothalamic or pituitary level. 

Limited evidence exists to correlate gonadotropins 
to behavioral functioning, although some observations 
have been made to warrant hypothetical consideration. 
Studies have indicated decreased levels of testosterone, 
LH, and FSH in depressed men. Increased sexual be- 
havior and aggressiveness have been linked to elevated 
testosterone levels in both men and women. Decreased 
plasma levels of LH and FSH commonly occur in pa- 
tients with anorexia nervosa. Supplemental estrogen 
therapy has resulted in improved mentation and mood 
in some depressed women. 

Melanocyte-Stimulating Hormone. MSH from the 
hypothalamus stimulates the pineal gland to secrete 
melatonin. The release of melatonin appears to depend 
on the onset of darkness and is suppressed by light. 
Studies of this hormone have indicated that environ- 
mental light can affect neuronal activity and influence 
circadian rhythms. Correlation between abnormal se- 
cretion of melatonin and symptoms of depression has 
led to the implication of melatonin in the etiology of 
mood disorders with seasonal pattern, in which indi- 
viduals become depressed only during the fall and win- 
ter months when the amount of daylight decreases. 


It is thought that a number of mental disorders have 
biological bases. As previously stated, this does not im- 
ply that psychosocial and sociocultural influences are 

2338_Ch03_033-057.indd 45 

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totally discounted, but that the systems of biology, psy- 
chology, and sociology are interacting systems. This 
has been clearly indicated by the fact that individuals 
experience biological changes in response to various 
environmental events. Indeed, biological implications 
present but one etiological explanation for psychiatric 

Anomalies of the Brain 

Some studies have shown a significant enlargement 
in cerebral ventricular size in the brains of individu- 
als with schizophrenia. Dilation of cortical sulci and 
fissures were also observed. Several studies have indi- 
cated that temporal lobe size may also be decreased in 
schizophrenia (Minzenberg et al, 2008). 

Functional cerebral asymmetries of the brain occur 
normally as they relate to language comprehension 
and speech production. Computerized studies with 
schizophrenic populations have suggested that some 
individuals with the disorder exhibit abnormal cere- 
bral asymmetry, reduced cerebellar volume, and brain 
density changes. 

A number of studies have reported neuropathology 
as identified by histological changes in the brains of in- 
dividuals with schizophrenia (Minzenberg et al, 2008). 
Regions where changes have been noted include lim- 
bic system, thalamus, basal ganglia, hippocampus, and 
frontal cortex. 

Neurotransmitter Hypothesis 

The neurotransmitter hypothesis suggests that schiz- 
ophrenia (or schizophrenia-like symptoms) may be 
caused by an excess of dopamine- dependent neuronal 
activity in the brain (Sadock & Sadock, 2007). This ex- 
cess activity may be related to increased production or 
release of the substance at nerve terminals, increased 
receptor sensitivity, or reduced activity of dopamine 

Various other biochemicals have been implicated in 
the predisposition to schizophrenia. Abnormalities in 
the neurotransmitters norepinephrine, serotonin, ace- 
tylcholine, and GAB A and the neuroregulators, such as 
prostaglandins and endorphins, have been suggested. 

Possible Endocrine Correlation 

Although the exact mechanism is unknown, there 
may be some correlation between decreased levels 
of the hormone prolactin and schizophrenia. The 

neurotransmitter dopamine, which is elevated in 
schizophrenia, acts as the prolactin-inhibiting fac- 
tor. By decreasing dopamine, antipsychotic medica- 
tions increase prolactin synthesis and release. Some 
studies with nonmedicated schizophrenic patients 
have shown an inverse relationship between prolac- 
tin concentrations and symptoms of schizophrenia 
(Wolkowitz & Rothschild, 2003). 

Mood Disorders 
Neuroanatomical Considerations 

The symptoms of mood disorders, as well as biological 
research findings, support the hypothesis that mood 
disorders involve pathology of the prefrontal cortex 
and the limbic system (particularly the hippocampus, 
the amygdala, the hypothalamus, and the cingulate 
gyrus). The limbic system plays a major role in the dis- 
charge of emotions. Stooped posture, motor slowness, 
and the minor cognitive impairment of depression in- 
dicate involvement of the basal ganglia. Dysfunction of 
the hypothalamus is suggested by alterations in sleep, 
appetite, and sexual behavior. 

Neurotransmitter Hypothesis 

Early studies have associated symptoms of depression 
with a functional deficiency of norepinephrine and 
dopamine, and mania with a functional excess of these 
amines. The neurotransmitter serotonin appears to 
remain low in both states. Norepinephrine has been 
identified as a key component in the mobilization of 
the body to deal with stressful situations. Neurons that 
contain serotonin are critically involved in the regula- 
tion of such diverse functions as sleep, temperature, 
pain sensitivity, appetite, locomotor activity, neuroen- 
docrine secretions, and mood. The level of dopamine 
in the mesolimbic system of the brain is thought to ex- 
ert a strong influence over human mood and behavior. 
A diminished supply of these biogenic amines inhibits 
the transmission of impulses from one neuronal fiber 
to another, causing a failure of the cells to fire or be- 
come charged. 

Possible Endocrine Correlation 

In clients who are depressed, the normal system of 
hormonal inhibition fails, resulting in a hypersecretion 
of Cortisol. This elevated serum Cortisol is the basis for 
the dexamethasone suppression test that is sometimes 
used to determine if an individual has somatically 
treatable depression. 

2338_Ch03_033-057.indd 46 

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Chapter 3 



Hypothyroidism has also been associated with de- 
pression. Diminished TSH from the anterior pitui- 
tary gland in response to administered thyrotropin- 
releasing factor is observed in approximately 2 5 percent 
of depressed persons. Hyperthyroidism has been as- 
sociated with symptoms of acute mania. 

A correlation may exist between abnormal secretion 
of melatonin from the pineal gland and mood disorder 
with seasonal pattern, in which individuals become de- 
pressed only during the fall and winter months when 
the secretion of melatonin increases in response to de- 
creased amounts of daylight. 

Anxiety Disorders 
Neuroanatomical Considerations 

The limbic system has been the focus of study in the 
correlation of brain pathology to anxiety disorders. 
Stimulation of this area has produced anxiety and 
fear responses in nonhuman primates. The cingu- 
late gyrus of the limbic system has been implicated 
in the pathophysiology of obsessive-compulsive 
disorder. The locus coeruleus has also been impli- 
cated as a pathophysiological site in anxiety disor- 
ders, particularly with panic disorder (Hollander & 
Simeon, 2008). 

Neurotransmitter Hypothesis 

The neurotransmitters most closely associated with 
anxiety disorders include norepinephrine, serotonin, 
and GABA. Norepinephrine causes hyperarousal and 
anxiety, and elevated levels are implicated in the etiol- 
ogy of panic disorder. Serotonin may play a role in the 
behaviors associated with obsessive- compulsive disor- 
der. This hypothesis has been supported by the positive 
effects seen when the disorder is treated with SSRIs, 
such as fluoxetine and clomipramine. GABA is a neu- 
rotransmitter that inhibits postsynaptic excitation, thus 
interrupting the progression of the electrical impulse at 
the synaptic junction. Enhancement of the GABA sys- 
tem is the mechanism of action by which the benzodi- 
azepines produce their calming effect in the treatment 
of anxiety disorders. 

Possible Endocrine Correlation 

Increased levels of TSH and prolactin have been ob- 
served in individuals with anxiety disorders. Some 
individuals with obsessive- compulsive disorder ex- 
hibit increased Cortisol levels (similar to those seen 
in depressive disorder). The role of neuroendocrine 

dysregulation in the etiology of anxiety disorders has 
not as yet been determined. 

Anorexia Nervosa 
Neuroanatomical Considerations 

Some computed tomographic (CT) studies have revealed 
enlarged cerebrospinal fluid (CSF) spaces (enlarged sulci 
and ventricles) during the starvation period in individu- 
als with anorexia nervosa (Sadock & Sadock, 2007). This 
finding appears to reverse itself by weight gain. 

Neurotransmitter Hypothesis 

Preliminary studies have indicated that there is prob- 
ably a dysregulation of dopamine, serotonin, and nore- 
pinephrine in individuals with anorexia nervosa (Halmi, 
2008). A decrease in serotonin turnover has been found 
in clients with both bulimia and anorexia, and low CSF 
norepinephrine levels were discovered in clients with 
long-term anorexia who have obtained a weight within 
at least 15 percent of their normal weight range. 

Possible Endocrine Correlation 

Some speculation has occurred regarding a primary 
hypothalamic dysfunction in anorexia nervosa. Studies 
consistent with this theory have revealed elevated CSF 
Cortisol levels and a possible impairment of dopamin- 
ergic regulation in people with anorexia (Halmi, 2008). 
Additional evidence in the etiological implication of 
hypothalamic dysfunction is gathered from the fact 
that many individuals with anorexia experience amen- 
orrhea before the onset of starvation and significant 
weight loss. 

Alzheimer's Disease 
Neuroanatomical Considerations 

Observation of a brain from an individual with 
Alzheimer's disease reveals diffuse atrophy with flat- 
tened cortical sulci and enlarged cerebral ventricles 
(Sadock & Sadock, 2007). Microscopic findings 
include senile plaques, neurofibrillary tangles, and 
neuronal loss. 

Neurotransmitter Hypothesis 

Research has indicated that in the brains of clients with 
Alzheimer's disease the enzyme required to produce ace- 
tylcholine is dramatically reduced, leading to a reduction 
in the amount of this neurotransmitter that is released to 

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cells in the cortex and hippocampus. Other neurotrans- 
mitters that are thought to be diminished in Alzheimer's 
disease are norepinephrine and somatostatin. Dimin- 
ished concentrations of these neurochemicals have been 
implicated in the pathophysiology of the disease. 

Possible Endocrine Correlation 

The hormone corticotropin has been reported to be de- 
creased in Alzheimer's disease (Sadock & Sadock, 2007). 


Several diagnostic procedures are used to detect al- 
teration in biological function that may contribute to 
psychiatric disorders. Following is an explanation of 
various examinations, the technique used, the purpose 
of the examination, and possible findings. This infor- 
mation is summarized in Table 3-2. 



For an electroencephalogram (EEG), electrodes 
are placed on the scalp in a standardized position. 

Amplitude and frequency of beta, alpha, theta, and 
delta brain waves are graphically recorded on paper 
by ink markers for multiple areas of the brain surface. 

Purpose/Possible Findings 

The EEG measures brain electrical activity and 
identifies dysrhythmias, asymmetries, or suppression 
of brain rhythms. It is used in the diagnosis of epi- 
lepsy, neoplasm, stroke, and metabolic or degenera- 
tive disease. 

Computerized EEG Mapping 

EEG tracings are summarized by computer-assisted 
systems in which various regions of the brain are iden- 
tified and functioning is interpreted by color coding or 
gray shading. 

Purpose/Possible Findings 

Computerized EEG mapping measures brain electri- 
cal activity. It is used largely in research to represent 
statistical relationships between individuals and groups 
or between two populations of subjects (e.g., clients 
with schizophrenia versus control subjects). 

Table 3- 

Diagnostic Procedures Used to Detect Altered Brain Functioning 




Electroencephalography (EEG) 

Measures brain electrical activity. 

Electrodes are placed on the scalp to meas- 
ure amplitude and frequency of brain 
waves. Results are graphically recorded. 

Computerized EEG mapping 

Measures brain electrical activity. Used 

EEG tracings are summarized. Regions of 

largely in research 

the brain are identified and functioning 
is interpreted by color coding or gray 

Computed tomographic (CT) scan 

Measures accuracy of brain structure. 

X-rays are taken of various transverse 
planes of the brain. Computer analysis 
reconstructs image of each segment. 

Magnetic resonance imaging (MRI) 

Measures anatomical and biochemical 

Within a strong magnetic field, energy is 

status of various segments of the brain. 

released, which is then computerized 
and transformed into an image. 

Positron emission tomography (PET) 

Measures specific brain activity and func- 

A radioactive substance is injected. 


Detectors relay data to a computer that 
interprets the signals and produces the 
image. Different colors indicate level of 
brain activity. 

Single photon emission computed tomog- 

Measures brain activity and functioning. 

The technique is similar to PET, but uses 

raphy (SPECT) 

longer-acting radioactive substance and 
different detectors. 

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Computed Tomographic Scan 

A CT scan may be used with or without contrast me- 
dium. X-rays are taken of various transverse planes of 
the brain while a computerized analysis produces a 
precise reconstructed image of each segment. 

Purpose/Possible Findings 

The CT scan measures the accuracy of brain structure 
to detect possible lesions, abscesses, areas of infarction, 
or aneurysm. This technology has also been used to 
identify various anatomical differences in clients with 
schizophrenia, organic mental disorders, and bipolar 

Magnetic Resonance Imaging 

In magnetic resonance imaging (MRI), within a strong 
magnetic field the nuclei of hydrogen atoms absorb and 
reemit electromagnetic energy that is computerized 
and transformed into image information. No radiation 
or contrast medium is used. 

Purpose/Possible Findings 

MRI measures the anatomical and biochemical status 
of various segments of the brain. It also detects brain 
edema, ischemia, infection, neoplasm, trauma, and other 
changes such as demyelination. Morphological differ- 
ences between the brains of clients with schizophrenia 
and those of control subjects have been noted. 

Positron Emission Tomography 

With positron emission tomography (PET), the cli- 
ent receives an intravenous injection of a radioactive 
substance (the type depends on the brain activity to 
be visualized). Detectors surround the head and relay 
data to a computer, which interprets the signals and 
produces the image. 

Purpose/Possible Findings 

PET measures specific brain functioning, such as glu- 
cose metabolism, oxygen utilization, blood flow, and, 
of particular interest in psychiatry, neurotransmitter/ 
receptor interaction. 

Single Photon Emission Computed 


The single photon emission computed tomography 
(SPECT) technique is similar to PET, but a longer- 
acting radioactive substance must be used to allow 
time for a gamma camera to rotate about the head and 
gather the data, which then are assembled by compu- 
ter into a brain image. 

Purpose/Possible Findings 

SPECT measures various aspects of brain functioning, 
as with PET; it also has been used to take images of 
activity or CSF circulation. 


The middle of the 20th century was a pivotal period 
in the treatment of the mentally ill. It was during this 
time that the phenothiazine class of antipsychotics was 
introduced into the United States. Before that time, 
they had been used in France as preoperative medica- 
tions. As Dr. Henri Laborit of the Hospital Boucicaut 
in Paris stated: 

It was our aim to decrease the anxiety of the patients 
to prepare them in advance for their postoperative 
recovery. With these new drugs, the phenothiazines, 
we were seeing a profound psychic and physical 
relaxation ... a real indifference to the environment 
and to the upcoming operation. It seemed to me 
these drugs must have an application in psychiatry. 
(Sage, 1984) 

Indeed, they have had a significant application 
in psychiatry. Not only have they helped many in- 
dividuals to function effectively, but they have also 
provided researchers and clinicians with information 
to study the origins and etiologies of mental illness. 
Knowledge gained from learning how these drugs 
work has promoted advancement in understand- 
ing how behavioral disorders develop. Dr. Arnold 
Scheibel, Director of the UCLA Brain Research 
Institute, stated: 

[When these drugs came out] there was a sense of 
disbelief that we could actually do something sub- 
stantive for the patients . . . see them for the first time 
as sick individuals and not as something bizarre that 
we could literally not talk to. (Sage, 1984) 

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Psychotropic medication 

Medication that affects psychic function, behavior, 
or experience. 

Historical Perspectives 

Historically, reaction to and treatment of the men- 
tally ill ranged from benign involvement to interven- 
tion some would consider inhumane. Individuals with 
mental illness were feared because of common beliefs 
associating the ill with demons or the supernatural. 
They were looked upon as loathsome and often were 

Beginning in the late 18th century, a type of "moral 
reform" in the treatment of persons with mental illness 
began to occur. Community and state hospitals con- 
cerned with the needs of persons with mental illness 
were established. Considered a breakthrough in the 
humanization of care, these institutions, however well 
intentioned, fostered the concept of custodial care. 
Clients were ensured the provision of food and shelter 
but received little or no hope of change for the future. 
As they became increasingly dependent on the institu- 
tion to fill their needs, the likelihood of their return to 
the family or community diminished. 

The early part of the 20th century saw the advent of 
the somatic therapies in psychiatry. Individuals with 
mental illness were treated with insulin shock therapy, 
wet sheet packs, ice baths, electroconvulsive therapy, 
and psychosurgery. Before 1950, sedatives and am- 
phetamines were the only significant psychotropic 
medications available. Even these had limited use 
because of their toxicity and addicting effects. Since 
the 1950s, the development of psychopharmacology 
has expanded to include widespread use of antipsy- 
chotic, antidepressant, and antianxiety medications. 
Research into how these drugs work has provided 
an understanding of the etiology of many psychiatric 

Psychotropic medications are not intended to 
"cure" the mental illness. Most mental health prac- 
titioners who prescribe these medications for their 
clients use them as an adjunct to individual or group 
psychotherapy. Although their contribution to psy- 
chiatric care cannot be minimized, it must be empha- 
sized that psychotropic medications relieve physical 
and behavioral symptoms. They do not resolve emo- 
tional problems. 

Role of the Nurse 

Ethical and Legal Implications 

Nurses must understand the ethical and legal impli- 
cations associated with the administration of psycho- 
tropic medications. Laws differ from state to state, but 
most adhere to the client's right to refuse treatment. 
Exceptions exist in emergency situations when it has 
been determined that clients are likely to harm them- 
selves or others. 


A thorough baseline assessment must be conducted 
before a client is placed on a regimen of psychophar- 
macological therapy. A history and physical examina- 
tion (see Chapter 7), an ethnocultural assessment (see 
Chapter 5), and a comprehensive medication assess- 
ment (see Box 3-2) are all essential components of this 

Medication Administration 
and Evaluation 

For the client in an inpatient setting, as well as for 
many others in partial hospitalization programs, day 
treatment centers, home health care, and other set- 
tings, the nurse is the key health-care professional in 
direct contact with the individual receiving the chem- 
otherapy. Medication administration is followed by a 
careful evaluation, including continuous monitoring 
for side effects and adverse reactions. The nurse also 
evaluates the therapeutic effectiveness of the medica- 
tion. It is essential for the nurse to have a thorough 
knowledge of psychotropic medications to be able to 
anticipate potential problems and outcomes associated 
with their administration. 

Client Education 

The information associated with psychotropic medica- 
tions is copious and complex. An important role of the 
nurse is to translate that complex information into terms 
that can be easily understood by the client. Clients must 
understand why the medication has been prescribed, 
when it should be taken, and what they may expect in 
terms of side effects and possible adverse reactions. They 
must know whom to contact when they have a question 
and when it is important to report to their physician. 
Medication education encourages client cooperation 

2338_Ch03_033-057.indd 50 

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and promotes accurate and effective management of the 
treatment regimen. 

How Do Psychotropics Work? 

Most of the medications have their effects at the 
neuronal synapse, producing changes in neurotrans- 
mitter release and the receptors to which they bind 
(see Fig. 3-7). Researchers hypothesize that most 

antidepressants work by blocking the reuptake of 
neurotransmitters, specifically serotonin and nore- 
pinephrine. Reuptake is the process of neurotrans- 
mitter inactivation by which the neurotransmitter is 
reabsorbed into the presynaptic neuron from which 
it had been released. Blocking the reuptake proc- 
ess allows more of the neurotransmitter to be avail- 
able for neuronal transmission. This mechanism of 

Box 3-2 Medication Assessment Tool 


. Client's Name_ 

Marital Status, 

Presenting Symptoms (subjective & objective). 



Diagnosis (DSM-IV-TR) 

Current Vital Signs: Blood Pressure: Sitting, 


Height Weight 

_; Standing, 

_; Pulse, 

CURRENT/PAST USE OF PRESCRIPTION DRUGS (Indicate with V or "p" beside name of drug whether current 
or past use): 



How Long Used Why Prescribed By Whom 

Side Effects/Results 

CURRENT/PAST USE OF OVER-THE-COUNTER DRUGS (Indicate with "c" or "p" beside name of drug whether 
current or past use): 



How Long Used Why Prescribed By Whom Side Effects/Results 

"p" beside name of drug): 


Amount Used 

How Often Used 

When Last Used Effects Produced 

Any allergies to food or drugs?. 

Any special diet considerations?. 


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Box 3-2 Medication Assessment Tool— cont'd 

Do you have (or have you ever had) any of the following? If yes, provide explanation on the back of this sheet. 

Yes No 

1. Difficulty 

2. Delayed 
wound healing 

3. Constipation 

4. Urination 

5. Recent change in 
elimination patterns 

6. Weakness or tremors 

7. Seizures 

8. Headaches 

9. Dizziness 

10. High blood pressure 

11. Palpitations 

12. Chest pain 

1 3 . Blood clots/ 
pain in legs 

14. Fainting spells 

15. Swollen ankles/ 

16. Asthma 

17. Varicose veins 

18. Numbness/tingling 

19. Ulcers 

20. Nausea/vomiting 

2 1 . Problems with 

Yes No 

22. Shortness of breath 

23. Sexual dysfunction 

24. Lumps in your 

25. Blurred or double 

26. Ringing in the ears 

27. Insomnia 

28. Skin rashes 

29. Diabetes 

30. Hepatitis (or other 
liver disease) 

3 1 . Kidney disease 

32. Glaucoma 

Yes No 

Are you pregnant or breastfeeding?_ 
Type of contraception used 

Date of last menses . 

Describe any restrictions/limitations that might interfere with your use of medication for your current problem._ 

Prescription orders: 

Patient teaching related to medications prescribed: 

Laboratory work or referrals prescribed: 

Nurse's signature . 

Client's signature . 

action may also result in undesirable side effects (see 
Table 3-3). Some antidepressants also block receptor 
sites that are unrelated to their mechanisms of ac- 
tion. These include alpha-adrenergic, histaminergic, 
and muscarinic cholinergic receptors. Blocking these 
receptors is also associated with the development of 
certain side effects. 

Antipsychotic medications block dopamine recep- 
tors, and some affect muscarinic cholinergic, hista- 
minergic, and alpha-adrenergic receptors. The "atypi- 
cal" antipsychotics block a specific serotonin receptor. 
Benzodiazepines facilitate the transmission of the 

inhibitory neurotransmitter gamma-aminobutyric 
acid (GAB A). The psychostimulants work by increas- 
ing norepinephrine, serotonin, and dopamine release. 
Although each psychotropic medication affects neu- 
rotransmission, the specific drugs within each class 
have varying neuronal effects. Their exact mecha- 
nisms of action are unknown. Many of the neuronal 
effects occur acutely; however, the therapeutic effects 
may take weeks to occur for some medications such as 
antidepressants and antipsychotics. Acute alterations 
in neuronal function do not fully explain how these 
medications work. Long-term neuropharmacological 

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in vesicles 


the synaptic cleft 

The transmission of electrical impulses from the axon terminal of one neuron to the dendrite of another is achieved by the cor 
trolled release of neurotransmitters into the synaptic cleft. Neurotransmitters include serotonin, norepinephrine, acetyl cholin 
dopamine, glutamate, gamma-aminobutyric acid (GABA), and histamine, among others. Prior to its release, the neurotransmi 
ter is concentrated into specialized synaptic vesicles. Once fired, the neurotransmitter is released into the synaptic cleft where 
encounters receptors on the postsynaptic membrane. Each neurotransmitter has receptors specific to it alone. Some neurotran 
mitters are considered to be excitatory, whereas others are inhibitory, a feature that determines whether another action potent! 
will occur. In the synaptic cleft, the neurotransmitter rapidly diffuses, is catabolized by enzymatic action, or is taken up by tf 
neurotransmitter transporters and returned to vesicles inside the axon terminal to await another action potential. 

Psychotropic medications exert their effects in various ways in this area of synaptic transmission. Reuptake inhibitors bloc 
reuptake of the neurotransmitters by the transporter proteins, thus resulting in elevated levels of extracellular neurotransmitte 
Drugs that inhibit catabolic enzymes promote excess buildup of the neurotransmitter at the synaptic site. 

Some drugs cause receptor blockade, thereby resulting in a reduction in transmission and decreased neurotransmitter activit 
These drugs are called antagonists. Drugs that increase neurotransmitter activity by direct stimulation of the specific recepto: 
are called agonists. 

FIGURE 3-7 Area of synaptic transmission that is altered by drugs. 

reactions to increased norepinephrine and serotonin 
levels relate more to their mechanisms of action. Re- 
cent research suggests that the therapeutic effects are 
related to the nervous system's adaptation to increased 
levels of neurotransmitters. These adaptive changes 
result from a homeostatic mechanism, much like a 
thermostat, that regulates the cell and maintains equi- 


The discipline of psychiatric/mental health nursing 
has always spoken of its role in holistic health care, but 

historical review reveals that emphasis has been placed 
on treatment approaches that focus on psychological 
and social factors. Psychiatric nurses must integrate 
knowledge of the biological sciences into their prac- 
tices if they are to ensure safe and effective care to 
people with mental illness. In the Surgeon General's 
Report on Mental Health (U.S. Department of Health 
and Human Services, 1999), Dr. David Satcher wrote: 

The mental health field is far from a complete 
understanding of the biological, psychological, and 
sociocultural bases of development, but development 
clearly involves interplay among these influences. 
Understanding the process of development requires 
knowledge, ranging from the most fundamental 

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Table 3- 

Effects of Psychotropic Medications on Neurotransmitters 

Example of Medication 


Action on Neurotransmitter 
and/or Receptor 

Inhibit reuptake of 
serotonin (5-HT) 

Physiological Effects 

Reduces depression 
Controls anxiety 
Controls obsessions 

Side Effects 

Nausea, agitation, headache, 
sexual dysfunction 

Tricyclic antidepressants 

Inhibit reuptake of 

Reduces depression 

Sexual dysfunction (NE and 

serotonin (5-HT) 

Relief of severe pain 


Inhibit reuptake of 

Prevent panic attacks 

Sedation, weight gain (H 2 ) 

norepinephrine (NE) 

Dry mouth, constipation, 

Block NE (oCj) receptor 

blurred vision, urinary reten- 

Block ACh receptor 

tion (ACh) 

Block histamine (H t ) 

Postural hypotension and 


tachycardia (oCj) 

MAO inhibitors 

Increase NE and 5-HT by 

Reduces depression 

Sedation, dizziness 

inhibiting the enzyme that 

Controls anxiety 

Sexual dysfunction 

degrades them (MAO-A) 

Hypertensive crisis (interaction 
with tyramine) 

Trazodone and Nefazodone 

5-HT reuptake block 

Reduces depression 

Nausea (5-HT) 

5-HT 2 receptor antagonism 

Reduces anxiety 

Sedation (5-HT 2 ) 

Adrenergic receptor blockade 

Orthostasis (a 2 ) 
Priapism (oc 2 ) 

SSNRIs: venlafaxine, 

Potent inhibitor of serotonin 

Reduces depression 

Nausea (5-HT) 

desvenlafaxine, and 

and norepinephrine reuptake 

Relieves pain of 

T sweating (NE) 


Weak inhibitor of dopamine 

neuropathy (duloxetine) 

Insomnia (NE) 


Relieves anxiety (venlafaxine) 

Tremors (NE) 

Sexual dysfunction (5-HT) 


Inhibits reuptake of NE and 

Reduces depression 

Insomnia, dry mouth, tremor, 

dopamine (D) 

Aid in smoking cessation 
-l symptoms of ADHD 



Strong D 2 receptor blockade 

Relief of psychosis 

Blurred vision, dry mouth, 

phenothiazines and 

Weaker blockade of ACh, H p 

Relief of anxiety 

decreased sweating, consti- 


alphaj -adrenergic, and 

(Some) provide relief from 

pation, urinary retention, 

5-HT 2 receptors 

nausea and vomiting and 

tachycardia (ACh) 

intractable hiccoughs 

EPS (D 2 ) 

T plasma prolactin (D 2 ) 
Sedation; weight gain (H t ) 
Ejaculatory difficulty (5-HT 2 ) 
Postural hypotension (a; H x ) 

Antipsychotics (Novel): 

Receptor antagonism of 

Relief of psychosis (with 

Potential with some of the 


5-HTj and 5-HT 2 

minimal or no EPS) 

drugs for mild EPS (D 2 ) 


Dj-D 5 (varies with 

Relief of anxiety 

Sedation, weight gain (H 2 ) 



Relief of acute mania 

Orthostasis and dizziness 





Alphaj -adrenergic 

Blurred vision, dry mouth, 


Muscarinic (ACh) 

decreased sweating, 


constipation, urinary 


retention, tachycardia 




Binds to BZ receptor sites 

Relief of anxiety 

Dependence (with 


on the GABA A receptor 


long-term use) 

complex; increases receptor 

Confusion; memory 

affinity for GABA 

impairment; motor 


5-HT 1A agonist 

Relief of anxiety 

Nausea, headache, dizziness 


D 2 agonist 
D 2 antagonist 


ACh, acetylcholine; ADHD, attention deficit-hyperactivity disorder; BZ, benzodiazepine; EPS, extrapyramidal symptoms; 
GABA, gamma-aminobutyric acid; 5-HT, 5 -hydroxy tryptamine (serotonin); MAO, monoamine oxidase; NE, norepinephrine. 

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Chapter 3 



level — that of gene expression and interactions 
between molecules and cells — all the way up to the 
highest levels of cognition, memory, emotion, and 
language. The challenge requires integration of 
concepts from many different disciplines. A fuller 
understanding of development is not only important 
in its own right, but it is expected to pave the way 
for our ultimate understanding of mental health and 
mental illness and how different factors shape their 
expression at different stages of the life span. 

To ensure a smooth transition from a psychosocial 
focus to one of biopsychosocial emphasis, nurses must 
have a clear understanding of the following: 

• Neuroanatomy and neurophysiology: The struc- 
ture and functioning of the various parts of the 
brain and their correlation to human behavior and 

• Neuronal processes: The various functions of the 
nerve cells, including the role of neurotransmit- 
ters, receptors, synaptic activity, and informational 

• Neuroendocrinology: The interaction of the en- 
docrine and nervous systems and the role that the 
endocrine glands and their respective hormones 
play in behavioral functioning. 

• Circadian rhythms: The regulation of biochemical 
functioning over periods of rhythmic cycles and its 
influence in predicting certain behaviors. 

• Genetic influences: The hereditary factors that pre- 
dispose individuals to certain psychiatric disorders. 

• Psychoimmunology: The influence of stress on 
the immune system and its role in the susceptibility 
to illness. 

• Psychopharmacology: The increasing use of psy- 
chotropic drugs in the treatment of mental illness, 
demanding greater knowledge of psychopharmaco- 
logical principles and nursing interventions necessary 
for safe and effective management. 

• Diagnostic technology: The importance of keep- 
ing informed about the latest in technological pro- 
cedures for diagnosing alterations in brain structure 
and function. 

Why are these concepts important to the practice of 
psychiatric/mental health nursing? The interrelation- 
ship between psychosocial adaptation and physical func- 
tioning has been established. Integrating biological and 
behavioral concepts into psychiatric nursing practice is 
essential for nurses to meet the complex needs of clients 
with mental illness. Psychobiological perspectives must 
be incorporated into nursing practice, education, and 

research to attain the evidence-based outcomes neces- 
sary for the delivery of competent care. 


■ A neurobiological transformation has occurred in 
psychiatry. Nurses must be cognizant of the in- 
teraction between physical and mental factors in 
the development and management of psychiatric 

■ Current trends have made it essential for nurses to 
increase their knowledge about the structure and 
functioning of the brain. This includes the processes 
of neurotransmission and the function of various 
neurotransmitters . 

This knowledge is especially important in light of 
the increasing role of psychotropic medication in 
the treatment of psychiatric illness. 
Because the mechanism of action of many of these 
drugs occurs at synaptic transmission, nurses must 
understand this process so that they may predict 
outcomes and safely manage the administration of 
psychotropic medications. 

The endocrine system plays an important role in hu- 
man behavior through the hypothalamic-pituitary 
axis. Hormones and their circadian rhythm of regu- 
lation significantly influence a number of physiologi- 
cal and psychological life-cycle phenomena, such 
as moods, sleep-arousal, stress response, appetite, 
libido, and fertility. 

It is important for nurses to keep abreast of the ex- 
panding diagnostic technologies available for de- 
tecting alterations in psychobiological functioning. 
Technologies such as magnetic resonance imagery 
(MRI) and positron emission tomography (PET) are 
facilitating the growth of knowledge linking mental 
illness to disorders of the brain. 
Psychotropic medications have given many individ- 
uals a chance to function effectively. 

■ Nurses must understand the ethical and legal im- 
plications associated with the administration of psy- 
chotropic medications. 

■ Nurses must have knowledge of the physiological 
mechanisms by which psychotropic medications ex- 
ert their effects. 

The holistic concept of nursing has never been 
stronger than it is today. Integrating knowledge of 
the expanding biological focus into psychiatric nurs- 
ing is essential if nurses are to meet the changing 
needs of today's psychiatric clients. 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 


1 . Which of the following parts of the brain is associated with multiple feelings and behaviors and is 
sometimes referred to as the "emotional brain"? 

a. Frontal lobe 

b. Thalamus 

c. Hypothalamus 

d. Limbic system 

2. Which of the following parts of the brain is concerned with visual reception and interpretation? 

a. Frontal lobe 

b. Parietal lobe 

c. Temporal lobe 

d. Occipital lobe 

3 . Which of the following parts of the brain is associated with voluntary body movement, thinking 
and judgment, and expression of feeling? 

a. Frontal lobe 

b. Parietal lobe 

c. Temporal lobe 

d. Occipital lobe 

4. Which of the following parts of the brain integrates all sensory input (except smell) on the way to 
the cortex? 

a. Temporal lobe 

b. Thalamus 

c. Limbic system 

d. Hypothalamus 

5. Which of the following parts of the brain deals with sensory perception and interpretation? 

a. Hypothalamus 

b. Cerebellum 

c. Parietal lobe 

d. Hippocampus 

6. Which of the following parts of the brain is concerned with hearing, short-term memory, and sense 
of smell? 

a. Temporal lobe 

b. Parietal lobe 

c. Cerebellum 

d. Hypothalamus 

7. Which of the following parts of the brain has control over the pituitary gland and autonomic 
nervous system? It also regulates appetite and temperature. 

a. Temporal lobe 

b. Parietal lobe 

c. Cerebellum 

d. Hypothalamus 

2338_Ch03_033-057.indd 56 

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8. At a synapse, the determination of further impulse transmission is accomplished by means of 
which of the following? 

a. Potassium ions 

b. Interneurons 

c. Neurotransmitters 

d. The myelin sheath 

9. A decrease in which of the following neurotransmitters has been implicated in depression? 

a. GAB A, acetylcholine, and aspartate 

b. Norepinephrine, serotonin, and dopamine 

c. Somatostatin, substance P, and glycine 

d. Glutamate, histamine, and opioid peptides 

10. Which of the following hormones has been implicated in the etiology of mood disorder with 
seasonal pattern? 

a. Increased levels of melatonin 

b. Decreased levels of oxytocin 

c. Decreased levels of prolactin 

d. Increased levels of thyrotropin 

1 1 . Psychotropic medications that block the reuptake of serotonin may result in which of the 
following side effects? 

a. Dry mouth 

b. Constipation 
Blurred vision 



d. Sexual dysfunction 

12. Psychotropic medications that block the acetylcholine receptor may result in which of the 
following side effects? 

a. Dry mouth 

b. Sexual dysfunction 

c. Nausea 

d. Priapism 

1 3 . Psychotropic medications that are strong blockers of the D 2 receptor are more likely to result in 
which of the following side effects? 

a. Sedation 

b. Urinary retention 

c. Extrapyramidal symptoms 

d. Hypertensive crisis 


Halmi, KA. (2008). Eating disorders: Anorexia nervosa, bulimia ner- 
vosa, and obesity. In R.E. Hales, S.C. Yudofsky, & G.O. Gabbard 
(Eds.). Textbook of clinical psychiatry (5th ed.). Washington, DC: 
American Psychiatric Publishing. 

Hamosh, A. (2005). Glycine encephalopathy. In GeneReviews at Gene 
Tests: Medical Genetics Information Resource (database online). 
Retrieved January 10, 2009 from 

Hollander, E., & Simeon, D. (2008). Anxiety disorders. In R.E. Hales, 
S.C. Yudofsky, & G.O. Gabbard (Eds.). Textbook of clinical psychiatry 
(5th ed.). Washington, DC: American Psychiatric Publishing. 

Joska, J.A, & Stein, D.J. (2008). Mood disorders. In R.E. Hales, 
S.C. Yudofsky, & G.O. Gabbard (Eds.). Textbook of clinical psychia- 
try (5th ed.). Washington, DC: American Psychiatric Publishing. 

Minzenberg, M.J., YoonJ.H., & Carter, C.S. (2008). Schizophrenia. 
In R.E. Hales, S.C. Yudofsky, & G.O. Gabbard (Eds.). Textbook of 

clinical psychiatry (5th ed.). Washington, DC: American Psychiatric 

Sadock, B.J., & Sadock, VA. (2007). Kaplan & Sadocks synopsis of 

psychiatry: Behavioral sciences/clinical psychiatry (10th ed.). 

Philadelphia: Lippincott Williams & Wilkins. 
Sage, D.L. (Producer). (1984). The Brain: Madness. [Television 

broadcast] . Washington, DC: Public Broadcasting Company. 
Scanlon, V.C., & Sanders, T (201 1). Essentials of anatomy and 

physiology (6th ed.). Philadelphia: FA. Davis. 
U.S. Department of Health and Human Services. (1999). Mental 

health: A report of the Surgeon General — Executive Summary. 

Rockville, MD: U.S. Department of Health and Human Services. 
Wolkowitz, O.M., & Rothschild, AJ. (2003). Psychoneuroendocrinology. 

Washington, DC: American Psychiatric Publishing. 

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9/1/10 2:17:41 PM 


H A P T E R 

Ethical and Legal Issues 











Christian ethics 

civil law 

common law 

criminal law 

defamation of character 


ethical dilemma 
ethical egoism 
false imprisonment 
informed consent 

natural law 



privileged communication 


statutory law 






moral behavior 


values clarification 


After reading this chapter, the student will be able to: 

1. Differentiate among ethics, morals, 
values, and rights. 

2. Discuss ethical theories including utili- 
tarianism, Kantianism, Christian ethics, 
natural law theories, and ethical egoism. 

3. Define ethical dilemma. 

4. Discuss the ethical principles of autono- 
my, beneficence, nonmaleficence, justice, 
and veracity. 

5. Use an ethical decision-making model to 
make an ethical decision. 

6. Describe ethical issues relevant to 
psychiatric/mental health nursing. 

7. Define statutory law and common law. 

8. Differentiate between civil and 
criminal law. 

9. Discuss legal issues relevant to 
psychiatric/mental health nursing. 




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10. Differentiate between malpractice and 

11. Identify behaviors relevant to the psy- 
chiatric/mental health setting for which 

specific malpractice action could be 


Please read the chapter and answer the following questions. 

1. Malpractice and negligence are examples 
of what type of law? 

2. With what may the nurse be charged for 
confining a client against his or her wish- 
es (outside of an emergency situation)? 

3. Which ethical theory espouses that what 
is right and good is what is best for the 
individual making the decision? 

4. Name the three major elements of in- 
formed consent. 


Nurses are constantly faced with the challenge of mak- 
ing difficult decisions regarding good and evil or life 
and death. Complex situations frequently arise in caring 
for individuals with mental illness, and nurses are held 
to the highest level of legal and ethical accountability 
in their professional practice. This chapter presents the 
basic ethical and legal concepts and their relationship 
to psychiatric/mental health nursing for the student 
and practicing nurse. A discussion of ethical theory is 
presented as a foundation upon which ethical decisions 

may be made. The American Nurses Association (ANA) 
(2001) has established a code of ethics for nurses to use 
as a framework within which to make ethical choices 
and decisions (Box 4—1). 

Because legislation determines what is right or good 
within a society, legal issues pertaining to psychiatric/ 
mental health nursing are also discussed in this chapter. 
Definitions are presented, along with rights of psychi- 
atric clients of which nurses must be aware. Nursing 
competency and client care accountability are com- 
promised when the nurse has inadequate knowledge 
about the laws that regulate the practice of nursing. 

Box 4-1 American Nurses Association Code of Ethics for Nurses 

1. The nurse, in all professional relationships, practices 
with compassion and respect for the inherent dignity, 
worth, and uniqueness of every individual, unrestricted 
by consideration of social or economic status, personal 
attributes, or the nature of health problems. 

2. The nurse's primary commitment is to the patient, 
whether an individual, family, group, or community. 

3. The nurse promotes, advocates for, and strives to pro- 
tect the health, safety, and rights of the patient. 

4. The nurse is responsible and accountable for individual 
nursing practice and determines the appropriate delega- 
tion of tasks consistent with the nurse's obligation to 
provide optimum patient care. 

5. The nurse owes the same duties to self as to others, in- 
cluding the responsibility to preserve integrity and safe- 
ty, to maintain competence, and to continue personal 
and professional growth. 

6. The nurse participates in establishing, maintaining, and 
improving health-care environments and conditions of 
employment conducive to the provision of quality health 
care and consistent with the values of the profession 
through individual and collective action. 

7. The nurse participates in the advancement of the pro- 
fession through contributions to practice, education, 
administration, and knowledge development. 

8. The nurse collaborates with other health professionals 
and the public in promoting community, national, and 
international efforts to meet health needs. 

9. The profession of nursing, as represented by associa- 
tions and their members, is responsible for articulating 
nursing values, for maintaining the integrity of the pro- 
fession and its practice, and for shaping social policy. 

Source: Reprinted with permission from American Nurses Association, Code of Ethics for Nurses with Interpretive Statements, © 2001 
American Nurses Publishing, American Nurses Foundation/American Nurses Association, Washington, DC. 


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Knowledge of the legal and ethical concepts presented 
in this chapter will enhance the quality of care the nurse 
provides in his or her psychiatric/mental health nursing 
practice and will also protect the nurse within the pa- 
rameters of legal accountability. Indeed, the very right to 
practice nursing carries with it the responsibility to main- 
tain a specific level of competency and to practice in ac- 
cordance with certain ethical and legal standards of care. 


Theoretical Perspectives 

An ethical theory is a moral principle or a set of moral 
principles that can be used in assessing what is morally 


Ethics is the science that deals with the Tightness 
and wrongness of actions (Aiken, 2004). Bioethics 
is the term applied to these principles when they 
refer to concepts within the scope of medicine, 
nursing, and allied health. 

Moral behavior is defined as conduct that results 
from serious critical thinking about how individuals 
ought to treat others. Moral behavior reflects the way 
a person interprets basic respect for other persons, 
such as the respect for autonomy, freedom, justice, 
honesty, and confidentiality (Pappas, 2006). 

Values are ideals or concepts that give meaning to 
the individual's life (Aiken, 2004). Values clarification 
is a process of self-exploration through which individ- 
uals identify and rank their own personal values. This 
process increases awareness about why individuals 
behave in certain ways. Values clarification is impor- 
tant in nursing to increase understanding about why 
certain choices and decisions are made over others 
and how values affect nursing outcomes. 

A right is defined as, "a valid, legally recognized 
claim or entitlement, encompassing both freedom 
from government interference or discriminatory 
treatment and an entitlement to a benefit or serv- 
ice" (Levy and Rubenstein, 1996). A right is abso- 
lute when there is no restriction whatsoever on 
the individual's entitlement. A legal right is one on 
which the society has agreed and formalized into 
law. Both the National League for Nursing (NLN) 
and the American Hospital Association (AHA) have 
established guidelines of patients' rights. Although 
these are not considered legal documents, nurses 
and hospitals are considered responsible for up- 
holding these rights of patients. 

right or morally wrong (Ellis & Hartley, 2008). These 
principles provide guidelines for ethical decision 


The basis of utilitarianism is "the greatest-happiness 
principle." This principle holds that actions are right 
to the degree that they tend to promote happiness and 
wrong as they tend to produce the reverse of happi- 
ness. Thus, the good is happiness and the right is that 
which promotes the good. Conversely, the wrongness 
of an action is determined by its tendency to bring 
about unhappiness. An ethical decision based on the 
utilitarian view looks at the end results of the decision. 
Action is taken based on the results that produce the 
most good (happiness) for the most people. 


Named for philosopher Immanuel Kant, Kantianism 
is directly opposed to utilitarianism. Kant argued that 
it is not the consequences or end results that make 
an action right or wrong; rather it is the principle or 
motivation on which the action is based that is the 
morally decisive factor. Kantianism suggests that our 
actions are bound by a sense of duty. This theory is of- 
ten called deontology (from the Greek word deon, which 
means "that which is binding; duty"). Kantian- directed 
ethical decisions are made out of respect for moral law. 
For example, "I make this choice because it is morally 
right and my duty to do so" (not because of considera- 
tion for a possible outcome). 

Christian Ethics 

A basic principle that might be called a Christian phi- 
losophy is that which is known as the golden rule: "Do 
unto others as you would have them do unto you" and, 
alternatively, "Do not do unto others what you would 
not have them do unto you." The imperative demand 
of Christian ethics is to treat others as moral equals 
and to recognize the equality of other persons by per- 
mitting them to act as we do when they occupy a posi- 
tion similar to ours. 

Natural Law Theories 

The most general moral precept of the natural law the- 
ory is "do good and avoid evil." Based on the writings of 

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St. Thomas Aquinas, natural law theory contends that 
ethics must be grounded in a concern for the human 
good. Although the nature of this "human good" is not 
expounded upon, Catholic theologians view natural law 
as the law inscribed by God into the nature of things — 
as a species of divine law. According to this conception, 
the Creator endows all things with certain potentialities 
or tendencies that serve to define their natural end. The 
fulfillment of a thing's natural tendencies constitutes the 
specific good of that thing. For example, the natural ten- 
dency of an acorn is to become an oak. What then is the 
natural potential, or tendency, of human beings? Natu- 
ral law theorists focus on an attribute that is regarded as 
distinctively human, as separating human beings from 
the rest of worldly creatures; that is, the ability to live 
according to the dictates of reason. It is with this ability 
to reason that humans are able to choose "good" over 
"evil." In natural law, evil acts are never condoned, even 
if they are intended to advance the noblest of ends. 

Ethical Egoism 

Ethical egoism espouses that what is right and good 
is what is best for the individual making the decision. 
An individual's actions are determined by what is to his 
or her own advantage. The action may not be best for 
anyone else involved, but consideration is only for the 
individual making the decision. 

Ethical Dilemmas 

An ethical dilemma is a situation that requires an in- 
dividual to make a choice between two equally unfa- 
vorable alternatives (Catalano, 2009). Evidence exists 
to support both moral "rightness" and moral "wrong- 
ness" related to a certain action. The individual who 
must make the choice experiences conscious conflict 
regarding the decision. 

Ethical dilemmas arise when no explicit reasons ex- 
ist that govern an action. Ethical dilemmas generally 
create a great deal of emotion. Often the reasons sup- 
porting each side of the argument for action are logi- 
cal and appropriate. The actions associated with both 
sides are desirable in some respects and undesirable in 
others. In most situations, taking no action is consid- 
ered an action taken. 

Ethical Principles 

Ethical principles are fundamental guidelines that 
influence decision making. The ethical principles of 
autonomy, beneficence, nonmaleficence, veracity, and 
justice are helpful and used frequently by health-care 
workers to assist with ethical decision making. 


The principle of autonomy arises from the Kantian 
duty of respect for persons as rational agents. This 
viewpoint emphasizes the status of persons as auton- 
omous moral agents whose right to determine their 
destinies should always be respected. This presumes 
that individuals are always capable of making inde- 
pendent choices for themselves. Health-care workers 
know this is not always the case. Children, comatose 
individuals, and the seriously mentally ill are exam- 
ples of clients who are incapable of making informed 
choices. In these instances, a representative of the 
individual is usually asked to intervene and give 
consent. However, health-care workers must ensure 
that respect for an individual's autonomy is not dis- 
regarded in favor of what another person may view 
as best for the client. 


Beneficence refers to one's duty to benefit or 
promote the good of others. Health-care workers 
who act in their clients' interests are beneficent, pro- 
vided their actions really do serve the client's best 
interest. In fact, some duties do seem to take pref- 
erence over other duties. For example, the duty to 
respect the autonomy of an individual may be over- 
ridden when that individual has been deemed harmful 
to self or others. Aiken (2004) states, "The difficulty 
that sometimes arises in implementing the princi- 
ple of beneficence lies in determining what exactly 
is good for another and who can best make that 

Peplau (1991) recognized client advocacy as an 
essential role for the psychiatric nurse. The term 
advocacy means acting in another's behalf — being a 
supporter or defender. Being a client advocate in 
psychiatric nursing means helping the client fulfill 
needs that, without assistance and because of their 
illness, may go unfulfilled. Individuals with mental 
illness are not always able to speak for themselves. 
Nurses serve in this manner to protect the client's 
rights and interests. Strategies include educating cli- 
ents and their families about their legal rights, ensur- 
ing that clients have sufficient information to make 
informed decisions or to give informed consent, and 
assisting clients to consider alternatives and support- 
ing them in the decisions they make. Additionally, 
nurses may act as advocates by speaking on behalf 
of individuals with mental illness to secure essential 
mental health services. 

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Nonmaleficence is the requirement that health-care 
providers do no harm to their clients, either inten- 
tionally or unintentionally (Aiken, 2004). Some phi- 
losophers suggest that this principle is more important 
than beneficence; that is, they support the notion that 
it is more important to avoid doing harm than it is to 
do good. In any event, ethical dilemmas often arise 
when a conflict exists between an individual's rights 
(the duty to promote good) and what is thought to 
best represent the welfare of the individual (the duty 
to do no harm). An example of this conflict might oc- 
cur when administering chemotherapy to a cancer pa- 
tient, knowing it will prolong his or her life, but create 
"harm" (adverse side effects) in the short term. 


The principle of justice has been referred to as the "jus- 
tice as fairness" principle. It is sometimes referred to as 
distributive justice, and its basic premise lies with the right 
of individuals to be treated equally regardless of race, 
sex, marital status, medical diagnosis, social standing, 
economic level, or religious belief (Aiken, 2004). The 
concept of justice reflects a duty to treat all individu- 
als equally and fairly. When applied to health care, this 
principle suggests that all resources within the society 
(including health-care services) ought to be distributed 
evenly without respect to socioeconomic status. Thus, 
according to this principle, the vast disparity in the qual- 
ity of care dispensed to the various classes within our 
society would be considered unjust. A more equitable 
distribution of care for all individuals would be favored. 


The principle of veracity refers to one's duty to always be 
truthml. Aiken (2004) states, "Veracity requires that the 
health-care provider tell the truth and not intentionally 
deceive or mislead clients." There are times when limita- 
tions must be placed on this principle, such as when the 
truth would knowingly produce harm or interfere with 
the recovery process. Being honest is not always easy, but 
lying is rarely justified. Clients have the right to know 
about their diagnosis, treatment, and prognosis. 

A Model for Making Ethical Decisions 

The following is a set of steps that may be used in mak- 
ing an ethical decision. These steps closely resemble 
the steps of the nursing process. 

1. Assessment: Gather the subjective and objective 
data about a situation. Consider personal values 

as well as values of others involved in the ethical 

2. Problem identification: Identify the conflict be- 
tween two or more alternative actions. 

3. Plan: 

a. Explore the benefits and consequences of each 

b. Consider principles of ethical theories. 

c. Select an alternative. 

4. Implementation: Act on the decision made and 
communicate the decision to others. 

5. Evaluation: Evaluate outcomes. 

A schematic of this model is presented in Figure 4-1. 
A case study using this decision-making model is pre- 
sented in Box 4-2. If the outcome is acceptable, action 
continues in the manner selected. If the outcome is un- 
acceptable, benefits and consequences of the remaining 
alternatives are reexamined, and steps 3 through 7 in 
Box 4—2 are repeated. 

Assessment of a 

A problem that 

requires action 

is identified 

Conflict exists between alternatives 


■ conflict 






Consider principles of ethical theories 


1 . To bring the greatest pleasure to the most people 

2. To perform one's duty: 

- duty to respect the patient's autonomy 

- duty to promote good 

- duty to do no harm 

- duty to treat all people equally and fairly 

- duty to always be truthful 

3. To do unto others as you would have them do unto you 

4. To promote the natural laws of God 

5. To consider that which is best for the decision maker 


Select an alternative 

Take action and communicate 

Evaluate the outcome 



FIGURE 4—1 Ethical decision-making model. 

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Box 4-2 Ethical Decision Making: A Case Study 

Step 1. Assessment 

Tonya is a 17-year-old girl who is currently on the psy- 
chiatric unit with a diagnosis of conduct disorder. Tonya 
reports that she has been sexually active since she was 14. 
She had an abortion when she was 15 and a second one 
just 6 weeks ago. She states that her mother told her she 
has "had her last abortion," and that she has to start taking 
birth control pills. She asks her nurse, Kimberly, to give her 
some information about the pills and to tell her how to go 
about getting some. Kimberly believes Tonya desperately 
needs information about birth control pills, as well as other 
types of contraceptives, but the psychiatric unit is part of a 
Catholic hospital, and hospital policy prohibits distributing 
this type of information. 

Step 2. Problem Identification 

A conflict exists between the client's need for information, 
the nurse's desire to provide that information, and the institu- 
tion's policy prohibiting the provision of that information. 

Step 3. Alternatives— Benefits and Consequences 

1 . Alternative 1 : Give the client information and risk los- 
ing job. 

2. Alternative 2: Do not give client information and com- 
promise own values of holistic nursing. 

3 . Alternative 3 : Refer client to another source outside the 
hospital and risk reprimand from supervisor. 

Step 4. Consider Principles of Ethical Theories 

1. Alternative 1: Giving the client information would 
certainly respect the client's autonomy and would ben- 
efit the client by decreasing her chances of becoming 
pregnant again. It would not be to the best advantage 
of Kimberly, in that she would likely lose her job. And 
according to the beliefs of the Catholic hospital, the 
natural laws of God would be violated. 

2 . Alternative 2 : Withholding information restricts the cli- 
ent's autonomy. It has the potential for doing harm, in 
that without the use of contraceptives, the client may be- 
come pregnant again (and she implies that this is not what 
she wants). Kimberly 's Christian ethic is violated in that 
this action is not what she would want "done unto her." 

3. Alternative 3: A referral would respect the client's 
autonomy, would promote good, would do no harm 
(except perhaps to Kimberly's ego from the possi- 
ble reprimand), and this decision would comply with 
Kimberly's Christian ethic. 

Step 5. Select an Alternative 

Alternative 3 is selected based on the ethical theories of 
utilitarianism (does the most good for the greatest number), 
Christian ethics (Kimberly's belief of "Do unto others as you 
would have others do unto you"), Kantianism (to perform 
one's duty), and the ethical principles of autonomy, benefi- 
cence, and nonmaleficence. The success of this decision de- 
pends on the client's follow-through with the referral and 
compliance with use of the contraceptives. 

Step 6. Take Action and Communicate 

Taking action involves providing information in writing 
for Tonya, perhaps making a phone call and setting up 
an appointment for her with Planned Parenthood. Com- 
municating suggests sharing the information with Tonya's 
mother. Communication also includes documentation of 
the referral in the client's chart. 

Step 7. Evaluate the Outcome 

An acceptable outcome might indicate that Tonya did in- 
deed keep her appointment at Planned Parenthood and is 
complying with the prescribed contraceptive regimen. It 
might also include Kimberly's input into the change proc- 
ess in her institution to implement these types of referrals 
to other clients who request them. 

An unacceptable outcome might be indicated by 
Tonya's lack of follow-through with the appointment 
at Planned Parenthood or lack of compliance in using 
the contraceptives, resulting in another pregnancy. 
Kimberly may also view a reprimand from her super- 
visor as an unacceptable outcome, particularly if she 
is told that she must select other alternatives should 
this situation arise in the future. This may motivate 
Kimberly to make another decision — that of seeking 
employment in an institution that supports a philosophy 
more consistent with her own. 

Ethical Issues in Psychiatric/Mental 
Health Nursing 

The Right to Refuse Medication 

The AHAs (1992) Patient's Bill of Rights states: "The 
patient has the right to refuse treatment to the extent 
permitted by law, and to be informed of the medical 
consequences of his action." In psychiatry, refusal of 
treatment primarily concerns the administration of psy- 
chotropic medications. "To the extent permitted by law" 
may be defined within the U.S. Constitution and several 

of its amendments (e.g., the First Amendment, which 
addresses the rights of speech, thought, and expression; 
the Eighth Amendment, which grants the right to free- 
dom from cruel and unusual punishment; and the Fifth 
and Fourteenth Amendments, which grant due process 
of law and equal protection for all). In psychiatry, "the 
medical consequences of his action" may include such 
steps as involuntary commitment, legal competency 
hearing, or client discharge from the hospital. 

Although many courts are supporting a client's 
right to refuse medications in the psychiatric area, 

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some limitations do exist. Weiss-Kaffie and Purtell 
(2001) state: 

The treatment team must determine that three crite- 
ria be met to force medication without client consent. 
The client must exhibit behavior that is dangerous to 
self or others; the medication ordered by the physi- 
cian must have a reasonable chance of providing help 
to the client; and clients who refuse medication must 
be judged incompetent to evaluate the benefits of the 
treatment in question, (p. 361) 

The Right to the Least-Restrictive 
Treatment Alternative 

Health-care personnel must attempt to provide treat- 
ment in a manner that least restricts the freedom of cli- 
ents. The "restrictiveness" of psychiatric therapy can be 
described in the context of a continuum, based on se- 
verity of illness. Clients may be treated on an outpatient 
basis, in day hospitals, or in voluntary or involuntary 
hospitalization. Symptoms may be treated with verbal 
rehabilitative techniques and move successively to be- 
havioral techniques, chemical interventions, mechanical 
restraints, or electroconvulsive therapy. The problem 
appears to arise in selecting the least restrictive means 
among involuntary chemical intervention, seclusion, and 
mechanical restraints. Sadock and Sadock (2007) state: 

Distinguishing among these interventions on the 
basis of restrictiveness proves to be a purely subjective 
exercise fraught with personal bias. Moreover, each of 
these three interventions is both more and less restric- 
tive than each of the other two. Nevertheless, the effort 
should be made to think in terms of restrictiveness 
when deciding how to treat patients, (p. 1376) 

j^ Box 4-3 Bill of Rights for Psychiatric 

1 . The right to appropriate treatment and related serv- 
ices in the setting that is most supportive and least 
restrictive to personal freedom. 

2 . The right to an individualized, written treatment or 
service plan; the right to treatment based on such 
plan; and the right to periodic review and revision of 
the plan based on treatment needs. 

3. The right, consistent with one's capabilities, to par- 
ticipate in and receive a reasonable explanation of the 
care and treatment process. 

4. The right to refuse treatment except in an emergency 
situation or as permitted by law. 

5. The right not to participate in experimentation in the 
absence of informed, voluntary, written consent. 

6. The right to freedom from restraint or seclusion ex- 
cept in an emergency situation. 

7. The right to a humane treatment environment that 
affords reasonable protection from harm and appro- 
priate privacy. 

8. The right to confidentiality of medical records (also 
applicable following patient's discharge). 

9. The right of access to medical records except infor- 
mation received from third parties under promise of 
confidentiality and when access would be detrimental 
to the patient's health (also applicable following pa- 
tient's discharge). 

10. The right of access to use of the telephone, personal 
mail, and visitors, unless deemed inappropriate for 
treatment purposes. 

1 1 . The right to be informed of these rights in compre- 
hensible language. 

12. The right to assert grievances if rights are infringed. 

1 3 . The right to referral as appropriate to other provid- 
ers of mental health services upon discharge. 

Source: Adapted from Mental Health Systems Act (1980). 


In 1980, the 96th Congress of the United States passed 
the Mental Health Systems Act, which includes a 
Patient's Bill of Rights, for recommendation to the states. 
An adaptation of these rights is presented in Box 4—3 . 

Nurse Practice Acts 

The legal parameters of professional and practical 
nursing are defined within each state by the state's 
nurse practice act. These documents are passed by 
the state legislature and in general are concerned with 
such provisions as the following: 

• The definition of important terms, including the 
definition of nursing and the various types of nurses 

• A statement of the education and other training or 
requirements for licensure and reciprocity 

• Broad statements that describe the scope of practice 
for various levels of nursing (APN, RN, LPN) 

• Conditions under which a nurse's license may be 
suspended or revoked, and instructions for appeal 

• The general authority and powers of the state board 
of nursing (Fedorka & Resnick, 2001). 

Most nurse practice acts are general in their 
terminology and do not provide specific guidelines 
for practice. Nurses must understand the scope 
of practice that is protected by their license and 
should seek assistance from legal counsel if they are 
unsure about the proper interpretation of a nurse 
practice act. 

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Types of Law 

There are two general categories or types of law that are 
of most concern to nurses: statutory law and common 
law. These laws are identified by their source or origin. 

Statutosry Law 

A statutory law is a law that has been enacted by a 
legislative body such as a county or city council, state 
legislature, or the U.S. Congress. An example of statu- 
tory law is the nurse practice acts. 

Common Law 

Common laws are derived from decisions made in 
previous cases. These laws apply to a body of principles 
that evolve from court decisions resolving various con- 
troversies. Because common law in the United States 
has been developed on a state basis, the law on specific 
subjects may differ from state to state. An example of a 
common law might be how different states deal with a 
nurse's refusal to provide care for a specific client. 

Classifications Within Statutory 
and Common Law 

Broadly speaking, there are two kinds of unlawful acts: 
civil and criminal. Both statutory law and common law 
have civil and criminal components. 

Civil Law 

Civil law protects the private and property rights 
of individuals and businesses. Private individuals or 
groups may bring a legal action to court for breach 
of civil law. These legal actions are of two basic types: 
torts and contracts. 


A tort is a violation of a civil law in which an indi- 
vidual has been wronged. In a tort action, one party 
asserts that wrongful conduct on the part of the other 
has caused harm and seeks compensation for harm suf- 
fered. A tort may be intentional or unintentional. Exam- 
ples of unintentional torts are malpractice and negli- 
gence actions. An example of an intentional tort is the 
touching of another person without that person's con- 
sent. Intentional touching (e.g., a medical treatment) 
without the client's consent can result in a charge of 
battery, an intentional tort. 


In a contract action, one party asserts that the other 
party, in failing to fulfill an obligation, has breached 
the contract, and either compensation or performance 
of the obligation is sought as remedy. An example is an 
action by a mental health professional whose clinical 
privileges have been reduced or terminated in viola- 
tion of an implied contract between the professional 
and a hospital. 

Criminal Law 

Criminal law provides protection from conduct 
deemed injurious to the public welfare. It provides for 
punishment of those found to have engaged in such 
conduct, which commonly includes imprisonment, 
parole conditions, a loss of privilege (e.g., a license), 
a fine, or any combination of these (Ellis & Hartley, 
2008). An example of a violation of criminal law is the 
theft by a hospital employee of supplies or drugs. 

Legal Issues in Psychiatric/Mental 
Health Nursing 

Confidentiality and Right to Privacy 

The Fourth, Fifth, and Fourteenth Amendments to 
the U.S. Constitution protect an individual's privacy. 
Most states have statutes protecting the confidentiality 
of client records and communications. The only indi- 
viduals who have a right to observe a client or have 
access to medical information are those involved in his 
or her medical care. 


Until 1996, client confidentiality in medical records was 
not protected by federal law. In August 1996, President 
Clinton signed the Health Insurance Portability and 
Accountability Act (HIPAA) into law. Under this law, 
individuals have the rights to access their medical 
records, to have corrections made to their medical 
records, and to decide with whom their medical infor- 
mation may be shared. The actual document belongs 
to the facility or the therapist, but the information con- 
tained therein belongs to the client. 

This federal privacy rule pertains to data called pro- 
tected health information (PHI) and applies to most indi- 
viduals and institutions involved in health care. Notice 
of privacy policies must be provided to clients upon 
entry into the health-care system. PHI are individually 
identifiable health information indicators and "relate 
to past, present, or future physical or mental health or 

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condition of the individual, or the past, present, or future 
payment for the provision of health care to an individual; 
and (1) that identifies the individual; or (2) with respect 
to which there is a reasonable basis to believe the in- 
formation can be used to identify the individual" (U.S. 
Department of Health and Human Services, 2003). 
These specific identifiers are listed in Box 4-4. 

Pertinent medical information may be released with- 
out consent in a life-threatening situation. If information 
is released in an emergency, the following information 
must be recorded in the client's record: date of disclo- 
sure, person to whom information was disclosed, rea- 
son for disclosure, reason written consent could not be 
obtained, and the specific information disclosed. 

Most states have statutes that pertain to the doctrine of 
privileged communication. Although the codes differ 
markedly from state to state, most grant certain profes- 
sionals privileges under which they may refuse to reveal 
information about, and communications with, clients. In 
most states, the doctrine of privileged communication 

J^ Box 4-4 Protected Health Information 
(PIH): Individually Identifiable 

1. Names 

2. Postal address information, (except state), including 
street address, city, county, precinct, and zip code 

3 . All elements of dates (except year) for dates directly 
related to an individual, including birth date, admis- 
sion date, discharge date, date of death; and all ages 
over 89 and all elements of dates (including year) in- 
dicative of such age, except that such ages and ele- 
ments may be aggregated into a single category of age 
90 or older 

4. Telephone numbers 

5. Fax numbers 

6. Electronic mail addresses 

7. Social Security numbers 

8. Medical record numbers 

9. Health plan beneficiary numbers 

10. Account numbers 

1 1 . Certificate/license numbers 

12. Vehicle identifiers and serial numbers, including 
license plate numbers 

13. Device identifiers and serial numbers 

14. Web universal resource locators (URLs) 

15. Internet protocol (IP) address numbers 

16. Biometric identifiers, including finger and voice 

17. Full-face photographic images and any comparable 

18. Any other unique identifying number, characteristic, 
or code 

Source: U.S. Department of Health and Human Services (2003). 

applies to psychiatrists and attorneys; in some instances, 
psychologists, clergy, and nurses are also included. 

In certain instances nurses may be called on to tes- 
tify in cases in which the medical record is used as 
evidence. In most states, the right to privacy of these 
records is exempted in civil or criminal proceedings. 
Therefore, it is important that nurses document with 
these possibilities in mind. Strict record keeping us- 
ing statements that are objective and nonjudgmental, 
having care plans that are specific in their prescrip- 
tive interventions, and keeping documentation that 
describes those interventions and their subsequent 
evaluation all serve the best interests of the client, the 
nurse, and the institution should questions regarding 
care arise. Documentation very often weighs heavily 
in malpractice case decisions. 

The right to confidentiality is a basic one, and espe- 
cially so in psychiatry. Although societal attitudes are 
improving, individuals have experienced discrimina- 
tion in the past for no other reason than for having a 
history of emotional illness. Nurses working in psy- 
chiatry must guard the privacy of their clients with 
great diligence. 

Exception: A Duty to Warn (Protection 
of a Third Party) 

There are exceptions to the laws of privacy and confi- 
dentiality. One of these exceptions stems from the 1974 
case of Tarasoff v. Regents of the University of California. 
The incident from which this case evolved came 
about in the late 1960s. A young man from Bengal, 
India (Mr. P.), who was a graduate student at the 
University of California (UC), Berkeley, fell in love 
with another university student (Ms. Tarasoff). Because 
she was not interested in an exclusive relationship with 
Mr. P., he became very resentful and angry. He began 
to stalk her and recorded some of their conversations 
in an effort to determine why she did not love him. 
He soon became very depressed and neglected his 
appearance, studies, and health. 

Ms. Tarasoff spent the summer of 1969 in South 
America. During this time, Mr. P. entered therapy 
with a psychologist at UC Berkeley's Cowell Memo- 
rial Hospital. He confided in the psychologist that he 
intended to kill his former girlfriend (identifying her 
by name) when she returned from vacation. The psy- 
chologist recommended civil commitment for Mr. P., 
claiming that he was suffering from acute and severe 
paranoid schizophrenia. Mr. P. was picked up by the 
campus police, but released a short time later because 
he appeared rational and promised to stay away from 
Ms. Tarasoff. Neither Ms. Tarasoff nor her parents 

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received any warning of the threat of Mr. P.'s intention 
to kill her. 

When Ms. Tarasoff returned to campus in October 
1969, Mr. P. resumed his stalking behavior and eventu- 
ally stabbed her to death. Ms. Tarasoff s parents sued 
the psychologist, several psychiatrists, and the univer- 
sity for failure to warn. The case was referred to the 
California Supreme Court, which ruled that a mental 
health professional has a duty not only to a client, but 
also to individuals who are being threatened by that 
client. The Court stated: 

Once a therapist does in fact determine, or under 
applicable professional standards reasonably should 
have determined, that a patient poses a serious danger 
of violence to others, he bears a duty to exercise rea- 
sonable care to protect the foreseeable victim of that 
danger. While the discharge of this duty of due care 
will necessarily vary with the facts of each case, in 
each instance the adequacy of the therapist's conduct 
must be measured against the traditional negligence 
standard of reasonable care under the circumstances. 
(Tarasoff v. Regents of University of California, 1974a) 

The defendants argued that warning the woman or 
her family would have breached professional ethics and 
violated the client's confidentiality and right to privacy. 
But the Court ruled that "... the confidential character 
of patient-psychotherapist communications must yield 
to the extent that disclosure is essential to avert dan- 
ger to others. The protective privilege ends where the 
public peril begins" (Tarasoff v. Regents of University of 
California, 1974b). 

In 1976, the California Supreme Court expanded the 
original case ruling (now referred to as Tarasoff I). The 
second ruling (known as Tarasoff II), broadened the rul- 
ing of "duty to warn" to include "duty to protect." They 
stated that, under certain circumstances, a therapist 
might be required to warn an individual, notify police, 
or take whatever steps are reasonably necessary to pro- 
tect an intended victim from harm. This duty to protect 
can also "occur in instances when patients, because of 
their vulnerable state and their inability to distinguish 
potentially harmful situations, must be protected by 
healthcare providers" (Guido, 2006, p. 383). 

The Tarasoff rulings created a great deal of contro- 
versy in the psychiatric community regarding breach 
of confidentiality and the subsequent negative impact 
on the client- therapist relationship. However, most 
states now recognize that therapists have ethical and 
legal obligations to prevent their clients from harming 
themselves or others. Many states have passed varia- 
tions on the original "protect and warn" legislation, 
but in most cases, courts have outlined the following 

guidelines for therapists to follow in determining their 
obligation to take protective measures: 

1 . Assessment of a threat of violence by a client to- 
ward another individual 

2 . Identification of the intended victim 

3 . Ability to intervene in a feasible, meaningful way to 
protect the intended victim 

When these guidelines apply to a specific situation, 
it is reasonable for the therapist to notify the victim, 
law enforcement authorities, relatives of the intend- 
ed victim, and/or to initiate voluntary or involuntary 
commitment of the client in an effort to prevent po- 
tential violence. 

Impl ications for Nursing. Advanced practice psychiatric 
nurses who are licensed to practice independently would 
be held to the same duty as other therapists. Generalist 
psychiatric nurses who are not acting independently, but 
rather under the supervision of a psychiatrist, neverthe- 
less have the responsibility to protect a third party who 
is being threatened by a client. If a client confides in 
the nurse the potential for harm to an intended victim, 
it is the duty of the nurse to report this information to 
the psychiatrist or to other team members. This is not a 
breach of confidentiality, and the nurse may be consid- 
ered negligent in the failure to do so. All members of the 
treatment team must be made aware of potential danger 
that the client poses to self or others. Detailed written 
documentation of the situation is also essential. 

Informed Consent 

According to law, all individuals have the right to de- 
cide whether to accept or reject treatment (Guido, 
2006). A health-care provider can be charged with 
assault and battery for providing life-sustaining treat- 
ment to a client when the client has not agreed to it. 
The rationale for the doctrine of informed consent 
is the preservation and protection of individual auton- 
omy in determining what will and will not happen to 
the person's body (Guido, 2006). 

Informed consent is a client's permission granted to 
a physician to perform a therapeutic procedure, before 
which information about the procedure has been pre- 
sented to the client with adequate time given for con- 
sideration about the pros and cons. The client should 
receive information such as what treatment alternatives 
are available; why the physician believes this treatment 
is most appropriate; the possible outcomes, risks, and 
adverse effects; the possible outcome should the client 
select another treatment alternative; and the possible 
outcome should the client choose to have no treatment. 

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An example of a treatment in the psychiatric area that 
requires informed consent is electroconvulsive therapy. 
There are some conditions under which treatment 
may be performed without obtaining informed consent. 
A client's refusal to accept treatment may be challenged 
under the following circumstances (Aiken, 2004; Guido, 
2006; Levy & Rubenstein, 1996; Mackay, 2001): 

1. When a client is mentally incompetent to make a 
decision and treatment is necessary to preserve life 
or avoid serious harm 

2. When refusing treatment endangers the life or 
health of another 

3. During an emergency, in which a client is in no 
condition to exercise judgment 

4. When the client is a child (consent is obtained from 
parent or surrogate) 

5. In the case of therapeutic privilege: Information 
about a treatment may be withheld if the physician 
can show that full disclosure would 

a. hinder or complicate necessary treatment, 

b. cause severe psychological harm, or 

c. be so upsetting as to render a rational decision 
by the client impossible. 

Although most clients in psychiatric/mental health 
facilities are competent and capable of giving informed 
consent, those with severe psychiatric illness often do 
not possess the cognitive ability to do so. If an indi- 
vidual has been legally determined to be mentally 
incompetent, consent is obtained from the legal guard- 
ian. Difficulty arises when no legal determination has 
been made, but the individual's current mental state 
prohibits informed decision making (e.g., the person 
who is psychotic, unconscious, or inebriated). In these 
instances, informed consent is usually obtained from 
the individual's nearest relative, or if none exist and 
time permits, the physician may ask the court to ap- 
point a conservator or guardian. When time does not 
permit court intervention, permission may be sought 
from the hospital administrator. 

A client or guardian always has the right to with- 
draw consent after it has been given. When this oc- 
curs, the physician should inform (or reinform) the 
client about the consequences of refusing treatment. 
If treatment has already been initiated, the physi- 
cian should terminate treatment in a way least likely 
to cause injury to the client and inform the client or 
guardian of the risks associated with interrupted treat- 
ment (Guido, 2006). 

The nurse's role in obtaining informed consent is 
usually defined by agency policy. A nurse may sign 
the consent form as witness for the client's signature. 

However, legal liability for informed consent lies with 
the physician. The nurse acts as client advocate to 
ensure that the following three major elements of in- 
formed consent have been addressed: 

1. Knowledge: The client has received adequate in- 
formation on which to base his or her decision. 

2 . Competency: The individual's cognition is not im- 
paired to an extent that would interfere with deci- 
sion making or, if so, that the individual has a legal 

3 . Free will: The individual has given consent volun- 
tarily without pressure or coercion from others. 

Restraints and Seclusion 

An individual's privacy and personal security are pro- 
tected by the U.S. Constitution and supported by the 
Mental Health Systems Act of 1980, out of which was 
conceived a Bill of Rights for psychiatric patients. 
These include "the right to freedom from restraint or 
seclusion except in an emergency situation." 

In psychiatry, the term restraints generally refers 
to a set of leather straps that are used to restrain the 
extremities of an individual whose behavior is out of 
control and who poses an inherent risk to the physical 
safety and psychological well-being of the individual 
and staff. Restraints are never to be used as punish- 
ment or for the convenience of staff. Other measures 
to decrease agitation, such as "talking down" (verbal 
intervention) and chemical restraints (tranquilizing 
medication) are usually tried first. If these interven- 
tions are ineffective, mechanical restraints may be 
instituted (although some controversy exists as to 
whether chemical restraints are indeed less restrictive 
than mechanical restraints). Seclusion is another type of 
physical restraint in which the client is confined alone 
in a room from which he or she is unable to leave. The 
room is usually minimally furnished with items to pro- 
mote the client's comfort and safety. 

The Joint Commission has released a set of revi- 
sions to its previous restraint and seclusion standards. 
The intent of these revisions is to reduce the use of 
this intervention as well as to provide greater assur- 
ance of safety and protection to individuals placed in 
restraints or seclusion for reasons related to psychi- 
atric disorders or substance abuse (Medscape Wire, 
2000). In addition to others, these provisions provide 
the following guidelines: 

1 . In the event of an emergency, restraints or seclusion 
may be initiated without a physician's order. 

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2. As soon as possible, but no longer than 1 hour af- 
ter the initiation of restraints or seclusion, a quali- 
fied staff member must notify the physician about 
the individual's physical and psychological condi- 
tion and obtain a verbal or written order for the 
restraints or seclusion. 

3 . Orders for restraints or seclusion must be reissued by 
a physician every 4 hours for adults age 1 8 and older, 
every 2 hours for children and adolescents ages 9 to 
17, and every hour for children younger than 9 years. 

4. An in-person evaluation of the individual must be 
made by the physician within 4 hours of the initia- 
tion of restraints or seclusion of an adult age 1 8 or 
older, and within 2 hours for children and adoles- 
cents ages 1 7 and younger. 

5. Minimum times for in-person reevaluations by 
a physician include 8 hours for individuals ages 
1 8 years and older, and 4 hours for individuals ages 
1 7 and younger. 

6. If an individual is no longer in restraints or seclu- 
sion when an original verbal order expires, the phy- 
sician must conduct an in-person evaluation within 
24 hours of initiation of the intervention. 

Clients in restraints or seclusion must be observed 
and assessed every 10 to 15 minutes with regard to cir- 
culation, respiration, nutrition, hydration, and elimi- 
nation. Such attention should be documented in the 
client's record. 

False imprisonment is the deliberate and unau- 
thorized confinement of a person within fixed limits 
by the use of verbal or physical means (Ellis & Hartley, 
2008). Health-care workers may be charged with false 
imprisonment for restraining or secluding — against 
the wishes of the client — anyone having been admit- 
ted to the hospital voluntarily. Should a voluntarily 
admitted client decompensate to a point that restraint 
or seclusion for protection of self or others is neces- 
sary, court intervention to determine competency and 
involuntary commitment is required to preserve the 
client's rights to privacy and freedom. 

Commitment Issues 
Voluntary Admissions 

Each year, more than 1 million persons are admitted 
to health-care facilities for psychiatric treatment, of 
which approximately two-thirds are considered volun- 
tary. To be admitted voluntarily, an individual makes 
direct application to the institution for services and 
may stay as long as treatment is deemed necessary. He 
or she may sign out of the treatment facility at any 

time, unless following a mental status examination 
the health-care professional determines that the cli- 
ent may be harmful to self or others and recommends 
that the admission status be changed from voluntary 
to involuntary. Although these types of admissions are 
considered voluntary, it is important to ensure that 
the individual comprehends the meaning of his or her 
actions, has not been coerced in any manner, and is 
willing to proceed with admission. 

Involuntary Commitment 

Because involuntary hospitalization results in sub- 
stantial restrictions of the rights of an individual, the 
admission process is subject to the guarantee of the 
Fourteenth Amendment to the U.S. Constitution 
that provides citizens protection against loss of lib- 
erty and ensures due process rights (Weiss-Kaffie & 
Purtell, 2001). Involuntary commitments are made 
for various reasons. Most states commonly cite the 
following criteria: 

• In an emergency situation (for the client who is 
dangerous to self or others) 

• For observation and treatment of mentally ill persons 

• When an individual is unable to take care of basic 
personal needs (the "gravely disabled") 

Under the Fourth Amendment, individuals are pro- 
tected from unlawful searches and seizures without 
probable cause. Therefore, the individual seeking the 
involuntary commitment must show probable cause 
why the client should be hospitalized against his or 
her wishes; that is, the person must show that there is 
cause to believe that the person would be dangerous to 
self or others, is mentally ill and in need of treatment, 
or is gravely disabled. 

Emergency Commitments 

Emergency commitments are sought when an individ- 
ual manifests behavior that is clearly and imminently 
dangerous to self or others. These admissions are usu- 
ally instigated by relatives or friends of the individual, 
police officers, the court, or health-care professionals. 
Emergency commitments are time limited, and a court 
hearing for the individual is scheduled, usually within 
72 hours. At that time, the court may decide that the 
client may be discharged; or, if deemed necessary, and 
voluntary admission is refused by the client, an addi- 
tional period of involuntary commitment may be or- 
dered. In most instances, another hearing is scheduled 
for a specified time (usually in 7 to 2 1 days). 

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The Mentally 111 Person in Need of Treatment 

A second type of involuntary commitment is for the ob- 
servation and treatment of mentally ill persons in need 
of treatment. Most states have established definitions 
of what constitutes "mentally ill" for purposes of state 
involuntary admission statutes. Some examples include 
individuals who, because of severe mental illness, are: 

• Unable to make informed decisions concerning 

• Likely to cause harm to self or others 

• Unable to fulfill basic personal needs necessary for 
health and safety 

In determining whether commitment is required, 
the court looks for substantial evidence of abnormal 
conduct — evidence that cannot be explained as the 
result of a physical cause. There must be "clear and 
convincing evidence" as well as "probable cause" to 
substantiate the need for involuntary commitment 
to ensure that an individual's rights under the Con- 
stitution are protected. The U.S. Supreme Court 
in O'Connor v. Donaldson held that the existence of 
mental illness alone does not justify involuntary hos- 
pitalization. State standards require a specific impact 
or consequence to flow from the mental illness that 
involves danger or an inability to care for one's own 
needs. These clients are entitled to court hearings 
with representation, at which time determination of 
commitment and length of stay are considered. Leg- 
islative statutes governing involuntary commitments 
vary from state to state. 

Involuntary Outpatient Commitment 

Involuntary outpatient commitment (IOC) is a court- 
ordered mechanism used to compel a person with 
mental illness to submit to treatment on an outpatient 
basis. A number of eligibility criteria for commitment 
to outpatient treatment have been cited (Appelbaum, 
2001; Maloy, 1996; Torrey & Zdanowicz, 2001). Some 
of these include the following: 

• A history of repeated decompensation requiring in- 
voluntary hospitalization 

• Likelihood that without treatment the individual 
will deteriorate to the point of requiring inpatient 

• Presence of severe and persistent mental illness 
(e.g., schizophrenia or bipolar disorder) and limited 
awareness of the illness or need for treatment 

• The presence of severe and persistent mental illness 
contributing to a risk of becoming homeless, incar- 
cerated, or violent or of committing suicide 

• The existence of individualized treatment plan 
likely to be effective and a service provider who has 
agreed to provide the treatment 

Most states have already enacted IOC legislation 
or currently have resolutions that speak to this topic 
on their agendas. Most commonly, clients who are 
committed into the IOC programs have severe and 
persistent mental illness, such as schizophrenia. The ra- 
tionale behind the legislation is to reduce the numbers of 
readmissions and lengths of hospital stays of these 
clients. Concern lies in the possibility of violating the 
individual rights of psychiatric clients without signifi- 
cant improvement in treatment outcomes. One study 
at Bellevue Hospital in New York found no difference 
in treatment outcomes between court-ordered out- 
patient treatment and voluntary outpatient treatment 
(Steadman et al, 2001). Other studies have shown 
positive outcomes, including a decrease in hospital re- 
admissions, with IOC (Ridgely, Borum, & Petrila, 2001; 
Swartz et al, 2001). Continuing research is required to 
determine if IOC will improve treatment compliance 
and enhance quality of life in the community for indi- 
viduals with severe and persistent mental illness. 

The Gravely Disabled Client 

A number of states have statutes that specifically define 
the "gravely disabled" client. For those that do not use 
this label, the description of the individual who, be- 
cause of mental illness, is unable to take care of basic 
personal needs is very similar. 

Gravely disabled is generally defined as a condition in 
which an individual, as a result of mental illness, is in 
danger of serious physical harm resulting from inabil- 
ity to provide for basic needs such as food, clothing, 
shelter, medical care, and personal safety. Inability to 
care for oneself cannot be established by showing that 
an individual lacks the resources to provide the neces- 
sities of life. Rather, it is the inability to make use of 
available resources. 

Should it be determined that an individual is gravely 
disabled, a guardian, conservator, or committee will be 
appointed by the court to ensure the management of 
the person and his or her estate. To legally restore com- 
petency then requires another court hearing to reverse 
the previous ruling. The individual whose competency 
is being determined has the right to be represented by 
an attorney. 

Nursing Liability 

Mental health practitioners — psychiatrists, psycholo- 
gists, psychiatric nurses, and social workers — have a 
duty to provide appropriate care based on the standards 

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of their professions and the standards set by law. The 
standards of care for psychiatric/mental health nursing 
are presented in Chapter 7. 

be expected to know what nursing interventions should 
have been carried out. Without the testimony of expert 
witnesses, a favorable verdict usually goes to the de- 
fendant nurse. 

Malpractice and Negligence 

The terms malpractice and negligence are often used 
interchangeably. Negligence has been defined as: 

The failure to exercise the standard of care that a 
reasonably prudent person would have exercised in 
a similar situation; any conduct that falls below the 
legal standard established to protect others against 
unreasonable risk of harm, except for conduct that 
is intentionally, wantonly, or willfully disregarded of 
others' rights. (Garner, 1999) 

Any person may be negligent. In contrast, malprac- 
tice is a specialized form of negligence applicable only 
to professionals. 

Black's Law Dictionary defines malpractice as: 

An instance of negligence or incompetence on the 
part of a professional. To succeed in a malpractice 
claim, a plaintiff must also prove proximate cause and 
damages. (Garner, 1999) 

In the absence of any state statutes, common law is 
the basis of liability for injuries to clients caused by 
acts of malpractice and negligence of individual prac- 
titioners. In other words, most decisions of negligence 
in the professional setting are based on legal precedent 
(decisions that have previously been made about simi- 
lar cases) rather than any specific action taken by the 

To summarize, when the breach of duty is charac- 
terized as malpractice, the action is weighed against 
the professional standard. When it is brought forth as 
negligence, action is contrasted with what a reasonably 
prudent professional would have done in the same or 
similar circumstances. 

Marchand (2001) cites the following basic elements 
of a nursing malpractice lawsuit: 

1 . The existence of a duty, owed by the nurse to a pa- 
tient, to conform to a recognized standard of care 

2 . A failure to conform to the required nursing stand- 
ard of care 

3 . Actual injury 

4. A reasonably close causal connection between the 
nurse's conduct and the patient's injury 

For the client to prevail in a malpractice claim, each 
of these elements must be proved. Juries' decisions are 
generally based on the testimony of expert witnesses 
because members of the jury are laypeople and cannot 

Types of Lawsuits That Occur 
in Psychiatric Nursing 

Most malpractice suits against nurses are civil actions; 
that is, they are considered breach of conduct actions 
on the part of the professional, for which compensa- 
tion is being sought. The nurse in the psychiatric set- 
ting should be aware of the types of behaviors that may 
result in charges of malpractice. 

Basic to the psychiatric client's hospitalization is his 
or her right to confidentiality and privacy. A nurse may 
be charged with breach of confidentiality for revealing 
aspects about a client's case, or even for revealing that 
an individual has been hospitalized, if that person can 
show that making this information known resulted in 

When shared information is detrimental to the cli- 
ent's reputation, the person sharing the information 
may be liable for defamation of character. When the 
information is in writing, the action is called libel. Oral 
defamation is called slander. Defamation of character 
involves communication that is malicious and false 
(Ellis & Hartley, 2008). Occasionally, libel arises out of 
critical, judgmental statements written in the client's 
medical record. Nurses need to be very objective in 
their charting, backing up all statements with factual 

Invasion of privacy is a charge that may result when a 
client is searched without probable cause. Many insti- 
tutions conduct body searches on psychiatric clients as 
a routine intervention. In these cases, there should be 
a physician's order and written rationale showing prob- 
able cause for the intervention. Many institutions are 
reexamining their policies regarding this procedure. 

Assault is an act that results in a person's genuine fear 
and apprehension that he or she will be touched without 
consent. Battery is the unconsented touching of anoth- 
er person. These charges can result when a treatment 
is administered to a client against his or her wishes and 
outside of an emergency situation. Harm or injury need 
not have occurred for these charges to be legitimate. 

For confining a client against his or her wishes, and 
outside of an emergency situation, the nurse may be 
charged with false imprisonment. Examples of actions 
that may invoke these charges include locking an indi- 
vidual in a room; taking a client's clothes for purposes 
of detainment against his or her will; and retaining in 

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mechanical restraints a competent, voluntary client 
who demands to be released. 

Avoiding Liability 

Hall and Hall (2001) suggest the following proactive 
nursing actions in an effort to avoid nursing malpractice: 

1 . Responding to the patient 

2 . Educating the patient 

3 . Complying with the standard of care 

4. Supervising care 

5. Adhering to the nursing process 

6. Documentation 

7. Follow-up 

In addition, it is a positive practice to develop and 
maintain a good interpersonal relationship with the 
client and his or her family. Some clients appear to 
be more "suit prone" than others. Suit-prone clients 
are often very critical, complaining, uncooperative, 
and even hostile. A natural response by the staff to 
these clients is to become defensive or withdrawn. 
Either of these behaviors increases the likelihood of 
a lawsuit should an unfavorable event occur (Ellis & 
Hartley, 2008). No matter how high the degree of 
technical competence and skill of the nurse, his or 
her insensitivity to a client's complaints and failure 
to meet the client's emotional needs often influence 
whether or not a lawsuit is generated. A great deal 
depends on the psychosocial skills of the health-care 


•Always put the client's rights and welfare first. 
• Develop and maintain a good interpersonal rela- 
tionship with each client and his or her family. 


Ethics is the science that deals with the Tightness and 

wrongness of actions. 

Bioethics is the term applied to these principles when 

they refer to concepts within the scope of medicine, 

nursing, and allied health. 

Moral behavior is defined as conduct that results 

from serious critical thinking about how individuals 

ought to treat others. 

Values are ideals or concepts that give meaning to 

the individual's life. 

A right is defined as "a valid, legally recognized claim 
or entitlement, encompassing both freedom from 
government interference or discriminatory treat- 
ment and an entitlement to a benefit or service." 
The ethical theory of utilitarianism is based on the 
premise that what is right and good is that which 
produces the most happiness for the most people. 
The ethical theory of Kantianism suggests that ac- 
tions are bound by a sense of duty and that ethical 
decisions are made out of respect for moral law. 
The code of Christian ethics is to treat others as 
moral equals and to recognize the equality of other 
persons by permitting them to act as we do when 
they occupy a position similar to ours. 
The moral precept of the natural law theory is "do 
good and avoid evil." Good is viewed as that which 
is inscribed by God into the nature of things. Evil 
acts are never condoned, even if they are intended 
to advance the noblest of ends. 
Ethical egoism espouses that what is right and good is 
what is best for the individual making the decision. 
Ethical principles include autonomy, beneficence, 
nonmaleficence, veracity, and justice. 
An ethical dilemma is a situation that requires an 
individual to make a choice between two equally un- 
favorable alternatives. 

Examples of ethical issues in psychiatric/mental 
health nursing include the right to refuse medica- 
tion and the right to the least-restrictive treatment 

Statutory laws are those that have been enacted by 
legislative bodies, and common laws are derived 
from decisions made in previous cases. Both types of 
laws have civil and criminal components. 
I Civil law protects the private and property rights 
of individuals and businesses, and criminal law pro- 
vides protection from conduct deemed injurious to 
the public welfare. 

Legal issues in psychiatric/mental health nursing 
center around confidentiality and the right to privacy, 
informed consent, restraints and seclusion, and com- 
mitment issues. 

Nurses are accountable for their own actions in rela- 
tion to these issues, and violation can result in mal- 
practice lawsuits against the physician, the hospital, 
and the nurse. 

Developing and maintaining a good interpersonal 
relationship with the client and his or her family ap- 
pears to be a positive factor when the question of 
malpractice is being considered. 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 

1 . Nurse Jones decides to go against family wishes and tell the client of his terminal status because 
that is what she would want if she were the client. Which of the following ethical theories is 
considered in this decision? 

a. Kantianism 

b. Christian ethics 

c. Natural law theories 

d. Ethical egoism 

2 . Nurse Jones decides to respect family wishes and not tell the client of his terminal status because 
that would bring the most happiness to the most people. Which of the following ethical theories 
considered in this decision? 

a. Utilitarianism 

b. Kantianism 

c. Christian ethics 

d. Ethical egoism 

3 . Nurse Jones decides to tell the client of his terminal status because she believes it is her duty to do 
so. Which of the following ethical theories is considered in this decision? 

a. Natural law theories 

b. Ethical egoism 

c. Kantianism 

d. Utilitarianism 



4. The nurse assists the physician with electroconvulsive therapy on his client who has refused to 
give consent. With which of the following legal actions might the nurse be charged because of this 
nursing action? 

a. Assault 

b. Battery 

c. False imprisonment 

d. Breach of confidentiality 

5. A competent, voluntary client has stated he wants to leave the hospital. The nurse hides his clothes 
in an effort to keep him from leaving. With which of the following legal actions might the nurse be 
charged because of this nursing action? 

a. Assault 

b. Battery 

c. False imprisonment 

d. Breach of confidentiality 

6. Joe is very restless and is pacing a lot. The nurse says to Joe, "If you don't sit down in the chair and 
be still, I'm going to put you in restraints!" With which of the following legal actions might the 
nurse be charged because of this nursing action? 

a. Defamation of character 

b. Battery 

c. Breach of confidentiality 

d. Assault 

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7. An individual may be considered gravely disabled for which of the following reasons? Select all that 

a. A person, because of mental illness, cannot fulfill basic needs. 

b. A mentally ill person is in danger of physical harm based on inability to care for self. 

c. A mentally ill person lacks the resources to provide the necessities of life. 

d. A mentally ill person is unable to make use of available resources to meet daily living 

8. Which of the following statements is (are) correct regarding the use of restraints? Select all that 

a. Restraints may never be initiated without a physician's order. 

b. Orders for restraints must be reissued by a physician every 2 hours for children and 

c. Clients in restraints must be observed and assessed every hour for issues regarding circulation, 
nutrition, respiration, hydration, and elimination. 

d. Adults in restraints must have an in-person reevaluation by a physician every 8 hours. 

9. Guidelines relating to "duty to warn" state that a therapist should consider taking action to warn a 
third party when his or her client (select all that apply): 

a. threatens violence toward another individual. 

b. identifies a specific intended victim. 

c. has command hallucinations. 

d. reveals paranoid delusions about another individual. 

10. Attempting to calm an angry client by using "talk therapy" is an example of which of the following 
clients' rights? 

a. The right to privacy 

b. The right to refuse medication 

c. The right to the least-restrictive treatment alternative 

d. The right to confidentiality 




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with interpretive statements. Washington, DC: ANA. 

Appelbaum, P.S. (2001, March). Thinking carefully about outpa- 
tient commitment. Psychiatric Services, 52(3), 347-350. 

Catalano, J.T. (2009). Nursing now! Todays issues, tomorrows trends 
(5th ed.). Philadelphia: FA. Davis. 

Ellis, J.R., & Hartley, C.L. (2008). Nursing in todays world: Trends, 
issues, and management (9th ed.). Philadelphia: Lippincott 
Williams & Wilkins. 

Fedorka, P., & Resnick, L.K. (2001). Defining nursing practice. In 
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practice and other legal rights. Philadelphia: FA Davis, pp. 97-1 17. 

Garner, B.A (Ed.). (1999). Black's law dictionary. St. Paul, MN: West 

Guido, G.W (2006). Legal and ethical issues in nursing (4th ed.). 
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Hall, J.K., & Hall, D. (2001). Negligence specific to nursing. In 
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Levy, R.M., & Rubenstein, L.S. (1996). The rights of people with 
mental disabilities. Carbondale, IL: Southern Illinois University 

Mackay,T.R. (2001). Informed consent. In M.E. O'Keefe (Ed.), 

Nursing practice and the law: Avoiding malpractice and other legal 

risks. Philadelphia: FA. Davis, pp. 199-213. 
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Research, policy and services. Durham, NC: Carolina Academic 

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risks. Philadelphia: FA. Davis, pp. 23-41. 
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Mental Health Systems Act. PL. 96-398, Title V, Sect. 501.94 

Stat. 1598, Oct 7, 1980. 
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(Eds.), Nursing today: Transition and trends (5th ed.). New York: 

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voluntary outpatient treatment: Empirical evidence and the experience 

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sciences /clinical psychiatry (10th ed.). Philadelphia: Lippincott 

Williams & Wilkins. 

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Swartz, M., Swanson, J., Hiday, V., Wagner, H.R., Burns, B., & 
Borum, R. (2001). A randomized controlled trial of outpatient 
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H A P T E R 

Cultural and Spiritual 

Concepts Relevant 

to Psychiatric/Mental 

Health Nursing 
















folk medicine 

culture religion 



ethnicity spirituality 




yin and yang 


After reading this ch« 

apter, the student will be able to: 



1. Define and differentiate between culture 
and ethnicity. 

2. Identify cultural differences based on six 
characteristic phenomena. 

3. Describe cultural variances, based on the 
six phenomena, for the following: 

a. Northern European Americans 

b. African Americans 

c. Native Americans 


d. Asian/Pacific Islander Americans 

e. Latino Americans 

f. Western European Americans 

g. Arab Americans and 
h. Jewish Americans 

4. Apply the nursing process in the care 
of individuals from various cultural 

2338_Ch05_076-104.indd 76 

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5. Define and differentiate between 
spirituality and religion. 

6. Identify clients' spiritual and religious 

7. Apply the six steps of the nursing process 
to individuals with spiritual and religious 


Please read the chapter and answer the following questions. 

1. Which cultural group may use a medicine 
man (or woman) called a shaman? 

2. Restoring a balance between opposite 
forces is a fundamental concept of Asian 
health practices. What is this called? 

3. Name five types of human spiritual needs. 

4. What is the second largest cultural group 
(after Caucasian) in the United States? 

5. What is the perception of mental illness 
in the Arab culture? 


What is culture? How does it differ from ethnicity? 
Why are these questions important? The answers lie 
in the changing face of America. Immigration is not 
new in the United States. Indeed, most U.S. citizens 
are either immigrants or descendents of immigrants 
and the number of foreign-born residents in this coun- 
try continues to grow on a yearly basis. This pattern 
continues because of the many individuals who want 
to take advantage of the technological growth and up- 
ward mobility that exists in this country. A breakdown 
of cultural groups in the United States is presented in 
Figure 5-1. 

Knowledge related to culture and ethnicity is impor- 
tant because these influences affect human behavior, 
its interpretation, and the response to it. Therefore, it 
is essential for nurses to understand the effects of these 
cultural influences if they are to work effectively with 


Culture describes a particular society's entire way 
of living, encompassing shared patterns of belief, 
feeling, and knowledge that guide people's conduct 
and are passed down from generation to genera- 
tion. Ethnicity is a somewhat narrower term and 
relates to people who identify with each other be- 
cause of a shared heritage (Griffith, Gonzalez, & 
Blue, 2003). 

the diverse U.S. population. Caution must be taken, 
however, not to assume that all individuals who share 
a cultural or ethnic group are identical or exhibit be- 
haviors perceived as characteristic of the group. This 
constitutes stereotyping and must be avoided. Many 
variations and subcultures occur within a culture. 
The differences may be related to status, ethnic back- 
ground, residence, religion, education, or other factors 
(Purnell & Paulanka, 2008). Every individual must be 
appreciated for his or her uniqueness. 

Native Hawaiian or 

Pacific Islander 


(4.3%) N 

Native American or 

Alaska Native 


African American 

Other race 

Two or 

more races 


Hispanic or Latino 



(59.5%) * 

5-1 Breakdown of cultural groups in the United 


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This chapter explores the ways in which various 
cultures differ. The nursing process is applied to the 
delivery of psychiatric/mental health nursing care 
for individuals from the following cultural groups: 
Northern European Americans, African Americans, 
Native Americans, Asian/Pacific Islander Americans, 
Latino Americans, Western European Americans, Arab 
Americans, and Jewish Americans. 


It is difficult to generalize about any one specific group 
in a country that is known for its heterogeneity. Within 
our American "melting pot," any or all characteristics 
could apply to individuals within any or all of the cul- 
tural groups represented. As these differences continue 
to be integrated, one American culture will eventually 
emerge. This is already evident in certain regions of 
the country today, particularly in the urban coastal 
areas. However, some differences still exist, and it is 
important for nurses to be aware of certain cultural 
influences that may affect individuals' behaviors and 
beliefs, particularly as they apply to health care. 

Giger and Davidhizar (2008) suggest six cultural 
phenomena that vary with application and use, yet are 
evidenced among all cultural groups: (1) communica- 
tion, (2) space, (3) social organization, (4) time, (5) envi- 
ronmental control, and (6) biological variations. 


All verbal and nonverbal behavior in connection with 
another individual is communication. Therapeutic com- 
munication has always been considered an essential part 
of the nursing process and represents a critical element 
in the curricula of most schools of nursing. Communi- 
cation has its roots in culture. Cultural mores, norms, 
ideas, and customs provide the basis for our way of think- 
ing. Cultural values are learned and differ from society 
to society. Communication is expressed through lan- 
guage (the spoken and written word), paralanguage 
(the voice quality, intonation, rhythm, and speed of the 
spoken word), and gestures (touch, facial expression, 
eye movements, body posture, and physical appear- 
ance). The nurse who is planning care must have an 
understanding of the client's needs and expectations 
as they are being communicated. As a third party, an 
interpreter often complicates matters, but one may 
be necessary when the client does not speak the same 
language as the nurse. Interpreting is a very com- 
plex process, however, that requires a keen sensitivity 
to cultural nuances, and not just the translating of 
words into another language. Tips for facilitating the 

communication process when using an interpreter are 
presented in Box 5-1. 


Spatial determinants relate to the place where the 
communication occurs and encompass the concepts 
of territoriality, density, and distance. Territoriality re- 
fers to the innate tendency to own space. The need 
for territoriality is met only if the individual has con- 
trol of a space, can establish rules for that space, and 
is able to defend the space against invasion or misuse 
by others (Giger & Davidhizar, 2008). Density, which 
refers to the number of people within a given envi- 
ronmental space, can influence interpersonal interac- 
tion. Distance is the means by which various cultures 
use space to communicate. Hall (1966) identified three 

Box 5-1 Using an Interpreter 

When using an interpreter, keep the following points 
in mind: 

• Address the client directly rather than speaking to the 
interpreter. Maintain eye contact with the client to 
ensure the client's involvement. 

• Do not interrupt the client and the interpreter. At times 
their interaction may take longer because of the need 
to clarify, and descriptions may require more time be- 
cause of dialect differences or the interpreter's aware- 
ness that the client needs more preparation before 
being asked a particular question. 

• Ask the interpreter to give you verbatim translations 
so that you can assess what the client is thinking and 

• Avoid using medical jargon that the interpreter or cli- 
ent may not understand. 

• Avoid talking or commenting to the interpreter at 
length; the client may feel left out and distrustful. 

• Be aware that asking intimate or emotionally laden 
questions may be difficult for both the client and the 
interpreter. Lead up to these questions slowly. Always 
ask permission to discuss these topics first, and prepare 
the interpreter for the content of the interview. 

• When possible, allow the client and the interpreter to 
meet each other ahead of time to establish some rap- 
port. If possible, try to use the same interpreter for suc- 
ceeding interviews with the client. 

• If possible, request an interpreter of the same gender as 
the client and of similar age. To make good use of the 
interpreter's time, decide beforehand which questions 
you will ask. Meet with the interpreter briefly before 
going to see the client so that you can let the inter- 
preter know what you are planning to ask. During the 
session, face the client and direct your questions to the 
client, not the interpreter. 

Source: Gorman, L.M., & Sultan, D.F. (2008). Psychosocial nursing 
for general patient care (3rd ed.). Philadelphia: FA. Davis. With 

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primary dimensions of space in interpersonal interac- 
tions in the Western culture: the intimate zone (0 to 
18 inches), the personal zone (18 inches to 3 feet), and 
the social zone (3 to 6 feet). 

Social Organization 

Cultural behavior is socially acquired through a process 
called enculturation, which involves acquiring knowl- 
edge and internalizing values (Giger & Davidhizar, 
2008). Children are acculturated by observing adults 
within their social organizations. Social organizations 
include families, religious groups, and ethnic groups. 


An awareness of the concept of time is a gradual learn- 
ing process. Some cultures place great importance on 
values that are measured by clock time. Punctuality 
and efficiency are highly valued in the United States, 
whereas some cultures are actually scornful of clock 
time. For example, some rural people in Algeria label 
the clock as the "devil's mill" and have no notion of 
scheduled appointment times or meal times (Giger & 
Davidhizar, 2008). They are totally indifferent to the 
passage of clock time, and they despise haste in all hu- 
man endeavors. Other cultural implications regarding 
time have to do with perception of time orientation. 
Whether individuals are present oriented or future 
oriented in their perception of time influences many 
aspects of their lives. 

Environmental Control 

The variable of environmental control has to do with 
the degree to which individuals perceive that they have 
control over their environment. Cultural beliefs and 
practices influence how an individual responds to his 
or her environment during periods of wellness and ill- 
ness. To provide culturally appropriate care, the nurse 
should not only respect the individual's unique beliefs, 
but should also have an understanding of how these 
beliefs can be used to promote optimal health in the 
client's environment. 

Biological Variations 

Biological differences exist among people in various 
racial groups. Giger & Davidhizar (2008) state: 

The strongest argument for including concepts 
on biological variations in nursing education and 
subsequently nursing practice is that scientific facts 
about biological variations can aid the nurse in giving 
culturally appropriate health care. (p. 145) 

These differences include body structure (both 
size and shape), skin color, physiological responses to 

medication, electrocardiographic patterns, suscepti- 
bility to disease, and nutritional preferences and de- 


Background Assessment Data 

A format for cultural assessment that may be used to 
gather information related to culture and ethnicity 
that is important for planning client care is provided 
in Box 5-2. 

Northern European Americans 

Northern European Americans have their ori- 
gins in England; Ireland; Wales; Finland; Sweden; 
Norway; and the Baltic states of Estonia, Latvia, and 
Lithuania. English is their primary language. Their 
language may also include words and phrases that 
reflect the influence of the languages spoken in the 
countries of their heritage. The descendants of these 
immigrants now make up what is considered the 
dominant cultural group in the United States today. 
Specific dialects and rate of speech are common to 
various regions of the country. 

Northern European Americans value territory. Per- 
sonal space is about 1 8 inches to 3 feet. 

With the advent of technology and widespread 
mobility, less emphasis has been placed on the cohesive- 
ness of the family. Data on marriage, divorce, and remar- 
riage in the United States show that 43 percent of first 
marriages end in separation or divorce within 15 years 
(Centers for Disease Control [CDC], 2001). The 
value that was once placed on religion also seems to be 
diminishing in the American culture. With the excep- 
tion of a few months following the terrorist attacks 
of September 11, 2001, when attendance increased, 
there has been a small decline reported in church 
attendance from 1992 to 2008 (Gallup, 2008). Punc- 
tuality and efficiency are highly valued in the culture 
that promoted the work ethic, and most within this 
cultural group tend to be future oriented (Murray, 
Zentner, & Yakimo, 2009). 

Northern European Americans, particularly those 
who achieve middle-class socioeconomic status, 
value preventive medicine and primary health care. 
This value follows along with the socioeconomic 
group's educational level, successful achievement, 
and financial capability to maintain a healthy lifestyle. 

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Box 5-2 Cultural Assessment Tool 

Client's name_ 

. Ethnic origin_ 
. Birth date 

. Relationship_ 

Name of significant other 

Primary language spoken Second language spoken_ 

How does client usually communicate with people who speak a different language?_ 
Is an interpreter required? Available? 

Highest level of education achieved :_ 
Presenting problem: 

. Occupation:, 

Has this problem ever occurred before?_ 

If so, in what manner was it handled previously? 

What is the client's usual manner of coping with stress ?_ 

Who is (are) the client's main support system(s)? 

Describe the family living arrangements: 

Who is the major decision maker in the family? 

Describe client's/family members' roles within the family:_ 

Describe religious beliefs and practices: 

Are there any religious requirements or restrictions that place limitations on the client's care?_ 
If so, describe: 

Who in the family takes responsibility for health concerns?. 
Describe any special health beliefs and practices: 

From whom does family usually seek medical assistance in time of need?_ 
Describe client's usual emotional/behavioral response to: 



Loss/change/failure :_ 


Describe any topics that are particularly sensitive or that the client is unwilling to discuss (because of cultural taboos): 

Describe any activities in which the client is unwilling to participate (because of cultural customs or taboos): 

What are the client's personal feelings regarding touch? 

What are the client's personal feelings regarding eye contact?_ 

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Box 5-2 Cultural Assessment Tool— cont'd 

What is the client's personal orientation to time? (past, present, future) 

Describe any particular illnesses to which the client may be bioculturally susceptible (e.g., hypertension and sickle cell 

disease in African Americans): 

Describe any nutritional deficiencies to which the client may be bioculturally susceptible (e.g., lactose intolerance in Native 

and Asian Americans): 

Describe client's favorite foods: 

Are there any foods the client requests or refuses because of cultural beliefs related to this illness (e.g., "hot" and "cold" 
foods for Latino Americans and Asian Americans)? If so, please describe: 

Describe client's perception of the problem and expectations of health care:_ 

Most recognize the importance of regular physical 

A typical diet for many Northern European 
Americans is high in fats and cholesterol and low 
in fiber. The good news is that people are learning 
to eating healthier by decreasing the amount of fat 
and increasing the nutrients in their diets. The bad 
news is that Americans still enjoy fast food, and it 
conforms to their fast-paced lifestyles. 

African Americans 

The language dialect of some African Americans is dif- 
ferent from what is considered standard English. The 
origin of the black dialect is not clearly understood 
but is thought to be a combination of various African 
languages and the languages of other cultural groups 
(e.g., Dutch, French, English, and Spanish) present in 
the United States at the time of its settlement. 

Personal space tends to be smaller than that of the 
dominant culture. 

Patterns of discrimination date back to the days 
of slavery, and evidence of segregation still exists, 
usually in the form of predominantly black neigh- 
borhoods, churches, and schools, which are still 
visible in some U.S. cities. Some African Americans 
find it difficult to assimilate into the mainstream cul- 
ture and choose to remain within their own social 

In 2004, 3 1 percent of African American households 
were headed by a woman (U.S. Census Bureau, 2007). 
Social support systems may be large and include 
sisters, brothers, aunts, uncles, cousins, boyfriends, 

girlfriends, neighbors, and friends. Many African 
Americans have a strong religious orientation, with 
the vast majority practicing some form of Protes- 
tantism (Pew Forum on Religion and Public Life, 

African Americans who have assimilated into the 
dominant culture are likely to be well educated, pro- 
fessional, and future oriented. Some who have not 
become assimilated may believe that planning for the 
future is hopeless, a belief based on their previous ex- 
periences and encounters with racism and discrimina- 
tion (Cherry & Giger, 2008). Among this group, some 
may be unemployed or have low-paying jobs, with lit- 
tle expectation for improvement. They are unlikely to 
value time or punctuality to the same degree as the 
dominant cultural group, which often causes them to 
be labeled as irresponsible. 

Some African Americans, particularly those from 
the rural South, may reach adulthood never having 
encountered a physician. They receive their medical 
care from the local folk practitioner known as "gran- 
ny" or "the old lady," or from an individual known as 
a "spiritualist." Incorporated into the system of folk 
medicine is the belief that health is a gift from God, 
whereas illness is a punishment from God or a retribu- 
tion for sin and evil. Historically, African Americans 
have turned to folk medicine either because they could 
not afford the cost of mainstream medical treatment 
or because of insensitive treatment by caregivers in the 
health-care delivery system. 

Hypertension occurs more frequently, and sickle cell 
disease occurs predominantly in African Americans. 
Hypertension carries a strong hereditary risk factor, 

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whereas sickle cell disease is genetically derived. 
Alcoholism is a serious problem among members of 
the black community, leading to a high incidence of 
alcohol-related illness and death (Cherry & Giger, 

The diet of most African Americans differs little 
from that of the mainstream culture. However, some 
African Americans follow their heritage and enjoy 
what has come to be known as "soul" food, which in- 
cludes poke salad, collard greens, beans, corn, fried 
chicken, black-eyed peas, grits, okra, and cornbread. 
These foods are now considered typical Southern 
fare and are regularly consumed and enjoyed by most 
individuals who inhabit the southern region of the 
United States. 

Native Americans 

The federal government currently recognizes 564 
American Indian tribes and Alaska Native groups. 
Approximately 200 tribal languages are still spoken, 
some by only a few individuals and others by many 
(Bureau of Indian Affairs [BIA], 2010). Fewer than half 
of these individuals still live on reservations, but many 
return regularly to participate in family and tribal life 
and sometimes to retire. 

Touch is an aspect of communication that is not 
the same among Native Americans as in the domi- 
nant American culture. Some Native Americans view 
the traditional handshake as somewhat aggressive. In- 
stead, if a hand is offered to another, it may be accepted 
with a light touch or just a passing of hands. Some 
Native Americans will not touch a dead person (Hanley, 

Native Americans may appear silent and reserved. 
They may be uncomfortable expressing emotions be- 
cause the culture encourages keeping private thoughts 
to oneself. Eye contact is avoided and considered rude 
(Hodgins & Hodgins, 2008). 

The concept of space is very concrete to Native 
Americans. Living space is often crowded with mem- 
bers of both nuclear and extended families. A large 
network of kin is very important to Native Americans. 
However, a need for extended space exists, as demon- 
strated by a distance of many miles between individual 
homes or camps on reservations. 

The primary social organizations of Native 
Americans are the family and the tribe. From infancy, 
Native American children are taught the importance 
of these units. Traditions are passed down by the eld- 
erly, and children are taught to respect tradition and to 
honor wisdom. 

Most Native Americans are very present-time ori- 
ented. The time sequences of importance for Native 
Americans are present, past, and future, with little em- 
phasis on the future (Purnell, 2009). Not only are Native 
Americans not ruled by the clock, some do not even own 
clocks. The concept of time is very casual, and tasks are 
accomplished, not with the notion of a particular time in 
mind, but merely in a present-oriented time frame. 

Religion and health practices are intertwined in the 
Native American culture. The medicine man (or woman) 
is called the shaman and may use a variety of methods in 
his or her practice. Some use crystals to diagnose illness, 
some sing and perform healing ceremonies, and some 
use herbs and other plants or roots to create remedies 
with healing properties. The Native American healers 
and U.S. Indian Health Service have worked together 
with mutual respect for many years. Hanley (2008) re- 
lates that a Native American healer may confer with a 
physician regarding the care of a client in the hospital. 
Clients may sometimes receive hospital passes to par- 
ticipate in a healing ceremony held outside the hospital. 
Research studies have continued to show the importance 
of each of these health-care systems in the overall well- 
ness of Native American people. 

The risks of illness and premature death from alco- 
holism, diabetes, tuberculosis, heart disease, accidents, 
homicide, suicide, pneumonia, and influenza are greater 
for Native Americans than for the U.S. population as 
a whole (Indian Health Service [IHS], 2009). Alcohol- 
ism is a significant problem among Native Americans 
(National Institute on Alcohol Abuse and Alcoholism 
[NIAAA], 2009). It is thought to be a symptom of de- 
pression in many cases and to contribute to a number of 
other serious problems, such as automobile accidents, 
homicides, spouse and child abuse, and suicides. 

Nutritional deficiencies are not uncommon among 
tribal Native Americans. Fruits and green vegeta- 
bles are often scarce in many of the federally defined 
Indian geographical regions. Meat and corn products 
are identified as preferred foods. Fiber intake is rel- 
atively low, while fat intake is often of the saturated 
variety. A large number of Native Americans living on 
or near reservations recognized by the federal or state 
government receive commodity foods supplied by the 
U.S. Department of Agriculture's food distribution 
program (U.S. Department of Agriculture, 2009). 

Asian/Pacific Islander Americans 

Asian Americans compose slightly more than 4 percent 
of the U.S. population. The Asian American culture 
includes peoples (and their descendants) from Japan, 

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China, Vietnam, the Philippines, Thailand, Cambodia, 
Korea, Laos, India, and the Pacific Islands. Although 
this discussion relates to these peoples as a single cul- 
ture, it is important to keep in mind that a multiplicity of 
differences regarding attitudes, beliefs, values, religious 
practices, and language exist among these subcultures. 

Many Asian Americans, particularly Japanese, are 
third and even fourth generation Americans. These 
individuals are likely to be acculturated to the U.S. 
culture. Kuo and Roysircar-Sodowsky (2000) describe 
three patterns common to Asian Americans in their at- 
tempt to adjust to the American culture: 

1. The traditionalists: These individuals tend to be 
the older generation Asians who hold on to the tra- 
ditional values and practices of their native culture. 
They have strong internalized Asian values. Prima- 
ry allegiance is to the biological family. 

2. The marginal people: These individuals reject the 
traditional values and totally embrace Western cul- 
ture. Often they are members of the younger gen- 

3 . Asian Americans: These individuals incorporate tra- 
ditional values and beliefs with Western values and 
beliefs. They become integrated into the American 
culture, while maintaining a connection with their 
ancestral culture. 

The languages and dialects of Asian Americans are 
very diverse. In general, they do share a similar be- 
lief in harmonious interaction. To raise one's voice is 
likely to be interpreted as a sign of loss of control. The 
English language is very difficult to master, and even 
bilingual Asian Americans may encounter communi- 
cation problems because of the differences in mean- 
ing assigned to nonverbal cues, such as facial gestures, 
verbal intonation and speed, and body movements. In 
Asian cultures, touching during communication has 
historically been considered unacceptable. However, 
with the advent of Western acculturation, younger 
generations of Asian Americans accept touching as 
more appropriate than did their ancestors. Eye contact 
is often avoided as it connotes rudeness and lack of re- 
spect in some Asian cultures. Acceptable personal and 
social spaces are larger than in the dominant American 
culture. Some Asian Americans have a great deal of dif- 
ficulty expressing emotions. Because of their reserved 
public demeanor, Asian Americans may be perceived as 
shy, cold, or uninterested. 

The family is the ultimate social organization in 
the Asian American culture, and loyalty to family 
is emphasized above all else. Children are expect- 
ed to obey and honor their parents. Misbehavior is 

perceived as bringing dishonor to the entire family. 
Filial piety (one's social obligation or duty to one's 
parents) is held in high regard. Failure to fulfill these 
obligations can create a great deal of guilt and shame 
in an individual. A chronological hierarchy exists, 
with the elderly maintaining positions of authority. 
Several generations, or even extended families, may 
share a single household. 

Although education is highly valued among Asian 
Americans, many remain under educated. Religious be- 
liefs and practices are very diverse and exhibit influences 
of Taoism, Buddhism, Confucianism, Islam, Hinduism, 
and Christianity (Giger & Davidhizar, 2008). 

Many Asian Americans are oriented to both the past 
and the present. Emphasis is placed on the wishes of 
one's ancestors, while adjusting to demands of the 
present. Little value is given to prompt adherence to 
schedules or rigid standards of activities. 

Restoring the balance of yin and yang is the funda- 
mental concept of Asian health practices. Yin and yang 
represent opposite forces of energy, such as negative/ 
positive, dark/light, cold/hot, hard/soft, and feminine/ 
masculine. The perception is that illness occurs when 
there is a disruption in the balance of these forces of 
energy. In medicine, the opposites are expressed as "hot" 
and "cold," and health is the result of a balance between 
hot and cold elements (Wang & Purnell, 2008). Food, 
medicines, and herbs are classified according to their 
hot and cold properties and are used to restore balance 
between yin and yang (cold and hot), thereby restoring 

Rice, vegetables, and fish are the main staple foods 
of Asian Americans. Milk is seldom consumed because 
a large majority of Asian Americans experience lactose 
intolerance. With Western acculturation, their diet is 
changing, and unfortunately, with more meat being con- 
sumed, the percentage of fat in the diet is increasing. 

Many Asian Americans believe that psychiatric ill- 
ness is merely behavior that is out of control. They 
view this as a great shame to the individual and the 
family. They often attempt to manage the ill person 
on their own until they can no longer handle the 
situation. It is not uncommon for Asian Americans 
to somaticize. Expressing mental distress through 
various physical ailments may be viewed as more 
acceptable than expressing true emotions (Xu & 
Chang, 2008). 

The incidence of alcohol dependence is low among 
Asians. This may be a result of a possible genetic in- 
tolerance of the substance. Some Asians develop un- 
pleasant symptoms, such as flushing, headaches, and 
palpitations, on drinking alcohol. Research indicates 

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that this is due to an isoenzyme variant that quickly 
converts alcohol to acetaldehyde and the absence of 
an isoenzyme that is needed to oxidize acetaldehyde. 
This results in a rapid accumulation of acetaldehyde 
that produces the unpleasant symptoms. 

Latino Americans 

Latino Americans are the fastest growing group of 
people in the United States, composing 14.7 percent 
of the population (U.S. Census Bureau, 2009). They 
represent the largest ethnic minority group. 

Latino Americans trace their ancestry to countries 
such as Mexico, Spain, Puerto Rico, Cuba, and other 
countries of Central and South America. The common 
language is Spanish, spoken with a number of dialects 
by the various peoples. Touch is a common form of 
communication among Latinos; however, they are very 
modest and are likely to withdraw from any infringe- 
ment on their modesty. Latinos tend to be very tact- 
ful and diplomatic and will often appear agreeable on 
the surface out of courtesy for the person with whom 
they are communicating. It is only after the fact when 
agreements remain unfulfilled that the true context of 
the interaction becomes clear. 

Latino Americans are very group oriented. It is 
important for them to interact with large groups of 
relatives, where a great deal of touching and embrac- 
ing occurs. The family is the primary social organiza- 
tion and includes nuclear family members as well as 
numerous extended family members. The traditional 
nuclear family is male dominated, and the father pos- 
sesses ultimate authority. 

Latino Americans tend to be oriented to the present. 
The concept of being punctual and giving attention to 
activities that relate to concern about the future are 
perceived as less important than present- oriented ac- 
tivities that cannot be retrieved at a later time. 

Roman Catholicism is the predominant religion 
among Latino Americans. Most Latinos identify with 
the Roman Catholic Church, even if they do not at- 
tend services. Religious beliefs and practices are likely 
to be strong influences in their lives. Especially in 
times of crisis, such as in cases of illness and hospi- 
talization, Latino Americans rely on priests and the 
family to carry out important religious rituals, such as 
promise making, offering candles, visiting shrines, and 
offering prayers (Spector, 2009). 

Folk beliefs regarding health are a combination of 
elements incorporating views of Roman Catholicism 
and Indian and Spanish beliefs. The folk healer is 
called a curandero (male) or curandera (female). 

Among traditional Latino Americans, the curandero 
is believed to have a gift from God for healing the 
sick and is often the first contact made when illness is 
encountered. Treatments used include massage, diet, 
rest, suggestions, practical advice, indigenous herbs, 
prayers, magic, and supernatural rituals (Gonzalez, 
Owen, & Esperat, 2008). Many Latino Americans still 
subscribe to the "hot and cold theory" of disease. This 
concept is similar to the Asian perception of yin and 
yang discussed earlier in this chapter. Diseases and the 
foods and medicines used to treat them are classified as 
"hot" or "cold," and the intention is to restore the body 
to a balanced state. 

Research indicates that there is less mental illness 
among Latino Americans than the general popula- 
tion. This may have to do with the strong cohesive- 
ness of the family and the support that is given during 
times of stress. Because Latino Americans have clearly 
defined rules of conduct, fewer role conflicts occur 
within the family. 

Western European Americans 

Western European Americans have their origins in 
France, Italy, and Greece. Each of these cultures pos- 
sesses its own language, in which a number of dialects 
are noticeable. Western Europeans are considered to 
be very warm and affectionate people. They tend to 
be physically expressive, using a lot of body language, 
including hugging and kissing. 

Like Latino Americans, Western European Americans 
are very family oriented. They interact in large groups, 
and it is not uncommon for several generations to live 
together or in close proximity. A strong allegiance to the 
cultural heritage exists, and it is not uncommon, particu- 
larly among Italians, to find settlements of immigrants 
clustering together. 

Roles within the family are clearly defined, with 
the man as the head of the household. Traditional 
Western European women view their role as mother 
and homemaker, and children are prized and cher- 
ished. The elderly are held in positions of respect and 
often are cared for in the home rather than placed in 
nursing homes. 

Roman Catholicism is the predominant religion for 
French and Italian people, Greek Orthodox for the 
Greek community. A number of religious traditions 
are observed surrounding rites of passage. Masses and 
rituals are observed for births, first communions, con- 
firmations, marriages, anniversaries, and deaths. 

Western Europeans tend to be present-time ori- 
ented, with a somewhat fatalistic view of the future. A 

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priority is placed on the here and now, and whatever 
happens in the future is perceived as God's will. 

Most Western European Americans follow health 
beliefs and practices of the dominant American cul- 
ture, but some folk beliefs and superstitions still en- 
dure. Spector (2009) reports the following supersti- 
tions and practices of Italians as they relate to health 
and illness: 

1. Congenital abnormalities can be attributed to the 
unsatisfied desire for food during pregnancy. 

2. If a pregnant woman is not given food that she 
craves or smells, the fetus will move inside, and a 
miscarriage can result. 

3 . If a pregnant woman bends or turns or moves in a 
certain way, the fetus may not develop normally. 

4. A woman must not reach during pregnancy because 
reaching can harm the fetus. 

5. Sitting in a draft can cause a cold that can lead to 

This author recalls her own Italian immigrant 
grandmother warming large collard greens in oil and 
placing them on swollen parotid glands during a bout 
with the mumps. The greens undoubtedly did nothing 
for the mumps, but they (along with the tender loving 
care) felt wonderful! 

Food is very important in the Western European 
American culture. Italian, Greek, and French cuisine 
is world famous, and food is used in a social manner, as 
well as for nutritional purposes. Wine is consumed by 
all (even the children, who are given a mixture of water 
and wine) and is the beverage of choice with meals. 
However, among Greek Americans, drunkenness en- 
genders social disgrace on the individual and the fam- 
ily (Papadopoulos & Purnell, 2008). 

Arab Americans* 

Arab Americans trace their ancestry and traditions to 
the nomadic desert tribes of the Arabian Peninsula. 
The Arab countries include Algeria, Bahrain, Comoros, 
Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, 
Mauritania, Morocco, Oman, Palestine, Qatar, Saudi 
Arabia, Somalia, Sudan, Syria, Tunisia, United Arab 
Emirates, and Yemen. First- wave immigrants, primarily 
Christians, came to the United States between 1887 
and 1913 seeking economic opportunity. First- wave 

*This section on Arab Americans is taken from Kulwicki, A.D. 
(2008). People of Arab heritage. In L.D. Purnell & B.J. Paulanka 
(Eds.), Transcultuml health care: A culturally competent approach 
(3rd ed.). © F.A. Davis. Used with permission. 

immigrants and their descendents typically resided 
in urban centers of the Northeast. Second-wave im- 
migrants entered the United States after World War II. 
Most are refugees from nations beset by war and political 
instability. This group includes a large number of profes- 
sionals and individuals seeking educational degrees who 
have subsequently remained in the United States. Most 
are Muslims and favor professional occupations. 

Arabic is the official language of the Arab world. 
Although English is a common second language, lan- 
guage and communication can pose formidable prob- 
lems in health-care settings. Communication is highly 
contextual, where unspoken expectations are more im- 
portant than the actual spoken words. While convers- 
ing, individuals stand close to one another, maintain 
steady eye contact, and touch (only between members 
of the same sex) the other's hand or shoulder. 

Speech may be loud and expressive and characterized 
by repetition and gesturing, particularly when involved 
in serious discussions. Observers witnessing impassioned 
communication may incorrectly assume that members 
of this culture are argumentative, confrontational, or 
aggressive. Privacy is valued, and many resist disclosure 
of personal information to strangers, especially when it 
relates to familial disease conditions. Among friends and 
relatives, Arabs express feelings freely. Devout Muslim 
men may not shake hands with women. When an Arab 
man is introduced to an Arab woman, the man waits for 
the woman to extend her hand. 

Punctuality is not taken seriously except in cases 
of business or professional meetings. Social events 
and appointments tend not to have a fixed beginning 
or end. 

Gender roles are clearly defined. The man is the 
head of the household and women are subordinate to 
men. Men are breadwinners, protectors, and decision 
makers. Women are responsible for the care and edu- 
cation of children and for the maintenance of a suc- 
cessful marriage by tending to their husbands' needs. 

The family is the primary social organization, and 
children are loved and indulged. The father is the dis- 
ciplinarian, and the mother is an ally and mediator. 
Loyalty to one's family takes precedence over person- 
al needs. Sons are responsible for supporting elderly 

Women value modesty, especially devout Muslims, 
for whom modesty is expressed with their attire. Many 
Muslim women view the practice oihijab, covering the 
body except for one's face and hands, as offering them 
protection in situations in which the sexes mix. 

Sickle cell disease and the thalassemias are common 
in the eastern Mediterranean. Sedentary lifestyle and 

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high fat intake among Arab Americans place them at 
higher risk for cardiovascular diseases. The rates of 
cholesterol testing, colorectal cancer screening, and 
uterine cancer screening are low; however, in recent 
years, the rate of mammography screening has in- 
creased dramatically. 

Arab cooking shares many general characteristics. 
Spices and herbs include cinnamon, allspice, cloves, 
ginger, cumin, mint, parsley, bay leaves, garlic, and on- 
ions. Bread accompanies every meal and is viewed as a 
gift from God. Lamb and chicken are the most popular 
meats. Muslims are prohibited from eating pork and 
pork products. Food is eaten with the right hand be- 
cause it is regarded as clean. Eating and drinking at 
the same time is viewed as unhealthy. Eating properly, 
consuming nutritious foods, and fasting are believed to 
cure disease. Gastrointestinal complaints are the most 
frequent reason for seeking health care. Lactose intol- 
erance is common. 

Most Arabs are Muslims. Islam is the religion of 
most Arab countries, and in Islam there is no sepa- 
ration of church and state; a certain amount of re- 
ligious participation is obligatory. Many Muslims 
believe in combining spiritual medicine, performing 
daily prayers, and reading or listening to the Qur'an 
with conventional medical treatment. The devout 
client may request that his or her chair or bed be 
turned to face Mecca and that a basin of water be 
provided for ritual washing or ablution before pray- 
ing. Sometimes illness is considered punishment for 
one's sins. 

Mental illness is a major social stigma. Psychiatric 
symptoms may be denied or attributed to "bad nerves" 
or evil spirits. When individuals suffering from mental 
distress seek medical care, they are likely to present 
with a variety of vague complaints such as abdominal 
pain, lassitude, anorexia, and shortness of breath. Cli- 
ents often expect and may insist on somatic treatment, 
at least vitamins and tonics. When mental illness is 
accepted as a diagnosis, treatment with medications, 
rather than counseling, is preferred. 

Jewish Americans 

To be Jewish is to belong to a specific group of peo- 
ple and a specific religion. The term Jewish does 
not refer to a race. The Jewish people came to 
the United States mostly from Spain, Portugal, 
Germany, and Eastern Europe (Schwartz, 2008). 
There are more than 5 million Jewish Americans 
living in the United States, and they live primarily 
in the larger urban areas. 

Four main Jewish religious groups exist today: 
Orthodox, Reform, Conservative, and Reconstruc- 
tionist. Orthodox Jews adhere to strict interpreta- 
tion and application of Jewish laws and ethics. They 
believe that the laws outlined in the Torah (the five 
books of Moses) are divine, eternal, and unalterable. 
Reform Judaism is the largest Jewish religious group 
in the United States. The Reform group believes in 
the autonomy of the individual in interpreting the 
Jewish code of laws, and a more liberal interpretation 
is followed. Conservative Jews also accept a less strict 
interpretation. They believe that the code of laws 
comes from God, but accept flexibility and adaptation 
of those laws to absorb aspects of the culture while 
remaining true to Judaism's values. The Reconstruc- 
tionists have modern views that generally override 
traditional Jewish laws. They do not believe that Jews 
are God's chosen people, and they reject the notion of 
divine intervention; Reconstructionists generally ac- 
cept interfaith marriage. 

The primary language of Jewish Americans is English. 
Hebrew, the official language of Israel and the Torah, is 
used for prayers and is taught in Jewish religious educa- 
tion. Early Jewish immigrants spoke a Judeo-German 
dialect called Yiddish, and some of those words have be- 
come part of American English (e.g., klutz, kosher, tush). 

Although traditional Jewish law is clearly male ori- 
ented, with acculturation little difference is seen to- 
day with regard to gender roles. Formal education is a 
highly respected value among the Jewish people. Over 
one-third of Jewish Americans hold advanced degrees 
and are employed as professionals (e.g., science, medi- 
cine, law, education), more than any other group with- 
in the U.S. white population. 

While most Jewish people live for today and plan 
for and worry about tomorrow, they are raised with 
stories of their past, especially of the Holocaust. 
They are warned to "never forget," lest history be 
repeated. Therefore, their time orientation is simul- 
taneously to the past, the present, and the future 
(Purnell & Selekman, 2008). 

Children are considered blessings and valued treas- 
ures, treated with respect, and deeply loved. They play 
an active role in most holiday celebrations and serv- 
ices. Respecting and honoring one's parents is one of 
the Ten Commandments. Children are expected to be 
forever grateful to their parents for giving them the 
gift of life (Purnell & Selekman, 2008). The rite of 
passage into adulthood occurs during a religious cer- 
emony called a bar or bat mitzvah (son or daughter of 
the commandment) and is usually commemorated by 
a family celebration. 

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Because of the respect afforded physicians and 
the emphasis on keeping the body and mind healthy, 
Jewish Americans are health conscious. In general, they 
practice preventive health care, with routine physical, 
dental, and vision screening. Circumcision for male in- 
fants is both a medical procedure and a religious rite 
and is performed on the eighth day of life. The proce- 
dure is usually performed at home and is considered a 
family festivity. 

A number of genetic diseases are more common in 
the Jewish population, including Tay- Sachs disease, 
Gaucher 's disease, and familial dysautonomia. Other 
conditions that occur with increased incidence in the 
Jewish population include inflammatory bowel disease 
(ulcerative colitis and Crohn's disease), colorectal can- 
cer, and breast and ovarian cancer. Jewish people have 
a higher rate of side effects from the antipsychotic 
clozapine. About 20 percent develop agranulocytosis, 
which has been attributed to a specific gene that was 
recently identified (Purnell & Selekman, 2008). 

Alcohol, especially wine, is an essential part of re- 
ligious holidays and festive occasions. It is viewed 
as appropriate and acceptable as long as it is used in 
moderation. For Jewish people who follow the dietary 
laws, a tremendous amount of attention is given to the 
slaughter of livestock and preparation and consump- 
tion of food. Religious laws dictate which foods are 
permissible. The term kosher means "fit to eat," and 
following these guidelines is considered a command- 
ment of God. Meat may be eaten only if the permitted 
animal has been slaughtered, cooked, and served fol- 
lowing kosher guidelines. Pigs are considered unclean, 
and pork and pork products are forbidden. Dairy prod- 
ucts and meat may not be mixed together in cooking, 
serving, or eating. 

Judaism opposes discrimination against people with 
physical, mental, and developmental conditions. The 
maintenance of one's mental health is considered just 
as important as the maintenance of one's physical 
health. Mental incapacity has always been recognized 
as grounds for exemption from all obligations under 
Jewish law (Purnell & Selekman, 2008). 

A summary of information related to the six cultural 
phenomena as they apply to the cultural groups dis- 
cussed here is presented in Table 5-1. 

Culture-Bound Syndromes 

The Diagnostic and Statistical Manual of Mental Disorders, 
Fourth Edition, Text Revision (DSM-IV-TR) (American 
Psychiatric Association [APA], 2000) recognizes vari- 
ous symptoms that are associated with specific cultures 
and that may be expressed differently from those of the 

dominant American culture. Although presentations 
associated with the major DSM-IV-TR categories can 
be found throughout the world, many of the responses 
are influenced by local cultural factors (APA, 2000). 
The DSM-IV-TR defines culture-bound syndromes 
as follows: 

Recurrent, locality-specific patterns of aberrant 
behavior and troubling experience that may or may 
not be linked to a particular DSM-IV diagnostic 
category. Many of these patterns are indigenously 
considered to be "illnesses," or at least afflictions, and 
most have local names, (p. I 

It is important for nurses to understand that indi- 
viduals from diverse cultural groups may exhibit these 
physical and behavioral manifestations. The syndromes 
are viewed within these cultural groups as folk, diag- 
nostic categories with specific sets of experiences and 
observations (APA, 2000). Examples of culture-bound 
syndromes are presented in Table 5-2. 

Diagnosis/Outcome Identification 

Nursing diagnoses are selected based on the informa- 
tion gathered during the assessment process. With 
background knowledge of cultural variables and infor- 
mation uniquely related to the individual, the follow- 
ing nursing diagnoses may be appropriate: 

• Impaired verbal communication related to cultural 
differences evidenced by inability to speak the dom- 
inant language 

• Anxiety (moderate to severe) related to entry into 
an unfamiliar health-care system and separation 
from support systems evidenced by apprehension 
and suspicion, restlessness, and trembling 

• Imbalanced nutrition, less than body requirements, 
related to refusal to eat unfamiliar foods provided in 
the health-care setting, evidenced by loss of weight 

• Spiritual distress related to inability to participate 
in usual religious practices because of hospitaliza- 
tion, evidenced by alterations in mood (e.g., anger, 
crying, withdrawal, preoccupation, anxiety, hostility, 

Outcome criteria related to these nursing diagnoses 
may include the following. 

The Client: 

1 . Has had all basic needs fulfilled 

2 . Has communicated with staff through an interpreter 

3. Has maintained anxiety at a manageable level by 
having family members stay with him or her during 

2338_Ch05_076-104.indd 87 

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Table 5-2 

Culture-Bound Syndromes 




Malaysia, Laos, Philippines, 
Polynesia, Papua 

New Guinea, 
Puerto Rico 


A dissociative episode followed by an outburst of violent, 
aggressive, or homicidal behavior directed at people and 
objects. May be associated with psychotic episode. 

Ataque de nervios 

Latin American and Latin 
Mediterranean groups 

Uncontrollable shouting, crying, trembling, verbal or physical 
aggression, sometimes accompanied by dissociative experi- 
ences, seizure-like or fainting episodes, and suicidal gestures. 
Often occurs in response to stressful family event. 

Bilis and colera (muina) 

Boufee delirante 

Latin American 

West Africa and Haiti 

Acute nervous tension, headache, trembling, screaming, 
stomach disturbances, and sometimes loss of consciousness. 
Thought to occur in response to intense anger or rage. 

Sudden outburst of agitated and aggressive behavior, confusion, 
and psychomotor excitement. May be accompanied by hal- 
lucinations or paranoia. 

Brain fag 

West Africa 

Difficulty concentrating, remembering, and thinking. Pain and 
pressure around head and neck; blurred vision. Associated 
with challenges of schooling. 



Severe anxiety and hypochondriasis associated with the 
discharge of semen, whitish discoloration of the urine, and 
feelings of weakness and exhaustion. 

Falling out or blacking out 

Ghost sickness 

Southern United States and 
the Caribbean 

American Indian tribes 

Sudden collapse. May or may not be preceded by dizziness. 
Person can hear but cannot move. Eyes are open, but indi- 
vidual claims inability to see. 

Preoccupation with death and the deceased. Bad dreams, weak- 
ness, feelings of danger, loss of appetite, fainting, dizziness, 
fear, anxiety, hallucinations, loss of consciousness, confusion, 
feelings of futility, and a sense of suffocation. 

Hwa-byung (anger syndrome) 


Insomnia, fatigue, panic, fear of impending death, dysphoric 
affect, indigestion, anorexia, dyspnea, palpitations, and gener- 
alized aches and pains. Attributed to the suppression of anger. 



Southern and Eastern Asia 

Malaysia, Indonesia 

Latinos in the United States 
and Latin America 

Sudden and intense anxiety that the penis (in males) or the 
vulva and nipples (in females) will recede into the body and 
cause death. 

Hypersensitivity to sudden fright, often with echopraxia, echo- 
lalia, and dissociative or trancelike behavior. 

Incoherence, agitation, hallucinations, ineffective social interac- 
tion, unpredictability, and possible violence. Attributed to 
genetics or environmental stress, or a combination of both. 

Mai de ojo (evil eye) 

Mediterranean cultures 

Occurs primarily in children. Fitful sleep, crying, diarrhea, 
vomiting, and fever. 


Latinos in the United States 
and Latin America 

Headaches, irritability, stomach disturbances, sleep difficulties, 
nervousness, easy tearfulness, inability to concentrate, trem- 
bling, tingling sensations, and dizziness. Occurs in response 
to stressful life experiences. 


Qi-gong psychotic reaction 

Eskimo cultures 


Abrupt dissociative episode accompanied by extreme excite- 
ment and sometimes followed by convulsions and coma 
lasting up to 12 hours. 

Dissociative, paranoid, or other psychotic or nonpsychotic 
symptoms that occur in individuals who become overly 
involved in the Chinese health-enhancing practice of qi-gong 
("exercise of vital energy"). 


African Americans, European 
Americans, Caribbean 

Anxiety, gastrointestinal complaints, weakness, dizziness, fear of 
being poisoned or killed. Symptoms are ascribed to hexing, 
witchcraft, sorcery, or the evil influence of another person. 

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Table 5- 

Culture-Bound Syndromes— cont'd 


Sangue dormido ("sleeping 


Shenjing shuairuo 



Portuguese Cape Verde 



Pain, numbness, tremor, paralysis, convulsions, stroke, blind- 
ness, heart attack, infection, and miscarriage. 

Physical and mental fatigue, dizziness, headaches, other pains, 
concentration difficulties, sleep disturbance, memory loss, 
gastrointestinal problems, sexual dysfunction, irritability, 
excitability, and various signs suggesting disturbance of the 
autonomic nervous system. 

Shenkui (Shenkuei) 


Taijin kyofusho 


China (Taiwan) 


Anxiety or panic, with dizziness, backache, fatigability, general 

weakness, insomnia, frequent dreams, and sexual dysfunction. 

Attributed to excessive semen loss. 
Anxiety, weakness, dizziness, fear, anorexia, insomnia, and 

gastrointestinal problems, with subsequent dissociation and 

possession by ancestral spirits. 


African Americans and 
European Americans in 
southern United States 

A trance state in which individuals "communicate" with de- 
ceased relatives or spirits. Not considered to be a folk illness, 
but may be misconstrued by clinicians as a psychosis. 

Susto ("fright" or "soul loss") 

Latin America, Mexico, 
Central America, and 
South America 

Appetite and sleep disturbances, sadness, pains, headache, stom- 
achache, and diarrhea. Attributed to a frightening event that 
causes the soul to leave the body and results in unhappiness 
and sickness. 


North African and Middle 
Eastern societies 

Fear that one's body, body parts, or its functions displease, em- 
barrass, or are offensive to other people in appearance, odor, 
facial expressions, or movements. 

Dissociative episodes that include shouting, laughing, hit- 
ting head against a wall, singing, or weeping. Person may 
withdraw and refuse to eat. Symptoms are attributed to being 
possessed by a spirit. 

Source: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. © 2000, American Psychiatric Association. 
With permission. 

4. Has maintained weight by eating foods that he or she 
likes brought to the hospital by family members 

5. Has restored spiritual strength through use of cultur- 
al rituals and beliefs and visits from a spiritual leader 


The following interventions have special cultural im- 
plications for nursing: 

1 . Use an interpreter if necessary to ensure that there are 
no barriers to communication. Be careful with non- 
verbal communication because it may be interpret- 
ed differently by different cultures (e.g., Asians and 
Native Americans may be uncomfortable with touch 
and direct eye contact, whereas Latinos and Western 
Europeans perceive touch as a sign of caring). 

2. Make allowances for individuals from other cul- 
tures to have family members around them and 
even participate in their care. Large numbers of 
extended family members are very important 
to African Americans, Native Americans, Asian 
Americans, Latino Americans, and Western 

European Americans. To deny access to these fam- 
ily support systems could interfere with the heal- 
ing process. 

3. Ensure that the individual's spiritual needs are be- 
ing met. Religion is an important source of support 
for many individuals, and the nurse must be toler- 
ant of various rituals that may be connected with 
different cultural beliefs about health and illness. 

4. Be aware of the differences in concept of time 
among the various cultures. Most members of the 
dominant American culture are future oriented and 
place a high value on punctuality and efficiency. 
Other cultures, such as African Americans, Native 
Americans, Asian Americans, Latino Americans, 
Arab Americans and Western European Americans, 
are more present- time oriented. Nurses must be 
aware that such individuals may not share the value 
of punctuality. They may be late to appointments 
and appear to be indifferent to some aspects of their 
therapy. Nurses must be accepting of these differ- 
ences and refrain from allowing existing attitudes to 
interfere with delivery of care. 

2338_Ch05_076-104.indd 91 

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5. Be aware of different beliefs about health care 
among the various cultures, and recognize the im- 
portance of these beliefs to the healing process. If 
an individual from another culture has been receiv- 
ing health care from a spiritualist, granny, curand- 
ero, or other nontraditional healer, it is important 
for the nurse to listen to what has been done in the 
past and even to consult with these cultural healers 
about the care being given to the client. 

6. Follow the health-care practices that the client 
views as essential, provided they do no harm or do 
not interfere with the healing process of the client. 
For example, the concepts of yin and yang and the 
"hot and cold" theory of disease are very impor- 
tant to the well-being of some Asians and Latinos, 
respectively. Try to ensure that a balance of these 
foods is included in the diet as an important rein- 
forcement for traditional medical care. 

7. Be aware of favorite foods of individuals from dif- 
ferent cultures. The health-care setting may seem 
strange and somewhat isolated, and for some indi- 
viduals it feels good to have anything around them 
that is familiar. They may even refuse to eat foods 
that are unfamiliar to them. If it does not interfere 
with his or her care, allow family members to pro- 
vide favorite foods for the client. 

8. The nurse working in psychiatry must realize that 
psychiatric illness is stigmatized in some cultures. 
Individuals who believe that expressing emotions 
is unacceptable (e.g., Asian Americans and Native 
Americans) will present unique problems when 
they are clients in a psychiatric setting. Nurses must 
have patience and work slowly to establish trust in 
order to provide these individuals with the assist- 
ance they require. 


Evaluation of nursing actions is directed at achieve- 
ment of the established outcomes. Part of the evalua- 
tion process is continuous reassessment to ensure that 
the selected actions are appropriate and the goals and 
outcomes are realistic. Including the family and ex- 
tended support systems in the evaluation process is es- 
sential if cultural implications of nursing care are to be 
measured. Modifications to the plan of care are made 
as the need is determined. 


Spirituality is difficult to describe. It cannot be seen, 
and it undoubtedly means something different to all 
people. Perhaps this is partly the reason it has been 




The human quality that gives meaning and sense 
of purpose to an individual's existence. Spiritual- 
ity exists within each individual regardless of belief 
system and serves as a force for interconnected- 
ness between the self and others, the environment 
and a higher power. 

somewhat ignored in the nursing literature. This as- 
pect is changing, however, with the following transfor- 
mations occurring in nursing: The inclusion of nursing 
responsibility for spiritual care is cited by the Inter- 
national Council of Nurses in their Code of Ethics and 
by the American Holistic Nurses Association in their 
Standards for Holistic Nursing Practice. The inclusion of 
spiritual care is also evidenced by the development of 
a nursing diagnostic category, Spiritual Distress, by 
NANDA International (Wright, 2005). In addition, 
contemporary research has produced evidence that 
spirituality and religion can make a positive difference 
in health and illness. 
Smucker (2001) states: 

Spirituality is the recognition or experience of a 
dimension of life that is invisible, and both within 
us and yet beyond our material world, providing a 
sense of connectedness and interrelatedness with the 
universe, (p. 5) 

Smucker (2001) identifies the following factors as 
types of spiritual needs associated with human beings: 

1 . Meaning and purpose in life 

2. Faith or trust in someone or something beyond 

3. Hope 

4. Love 

5. Forgiveness 

Spiritual Needs 

Meaning and Purpose in Life 

Humans by nature appreciate order and structure in 
their lives. Having a purpose in life gives one a sense 
of control and the feeling that life is worth living. 
Smucker (2001) states, "Meaning provides us with a 
basic understanding of life and our place in it" (p. 6). 
Walsh (1999) describes "seven perennial practices" 
that he believes provide meaning and purpose to life. 
He suggests that these practices promote enlightenment 

2338_Ch05_076-104.indd 92 

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and transformation and encourage spiritual growth. 
He identifies the seven perennial practices as follows: 

1 . Transform your motivation: Reduce craving and 
find your soul's desire. 

2 . Cultivate emotional wisdom: Heal your heart and 
learn to love. 

3 . Live ethically: Feel good by doing good. 

4. Concentrate and calm your mind: Accept the 
challenge of mastering attention. 

5. Awaken your spiritual vision: See clearly and rec- 
ognize the sacred in all things. 

6. Cultivate spiritual intelligence: Develop wisdom 
and understand life. 

7. Express spirit in action: Embrace generosity and 
the joy of service, (p. 14) 

In the final analysis, each individual must determine 
his or her own perception of what is important and 
what gives meaning to life. Throughout one's exist- 
ence, the meaning of life will undoubtedly be chal- 
lenged many times. A solid spiritual foundation may 
help an individual confront the challenges that result 
from life's experiences. 


Faith is often thought of as the acceptance of a belief in 
the absence of physical or empirical evidence. Smucker 
(2001) states: 

For all people, faith is an important concept. From 
childhood on, our psychological health depends on 
having faith or trust in something or someone to help 
meet our needs, (p. 7) 

Having faith requires that individuals rise above that 
which they can only experience through the five senses. 
Indeed, faith transcends the appearance of the physical 
world. An increasing amount of medical and scientific 
research is showing that what individuals believe exists 
can have as powerful an impact as what actually exists. 
Karren and associates (2006) state: 

Personal belief gives us an unseen power that 
enables us to do the impossible, to perform 
miracles — even to heal ourselves. It has been 
found that patients who exhibit faith become less 
concerned about their symptoms, have less-severe 
symptoms, and have less-frequent symptoms with 
longer periods of relief between them than patients 
who lack faith, (p. 473) 

Evidence suggests that faith, combined with con- 
ventional treatment and an optimistic attitude, can be 
a very powerful element in the healing process. 


Hope has been defined as a special kind of positive ex- 
pectation (Karren et al, 2006). With hope, individuals 
look at a situation, and no matter how negative, find 
something positive on which to focus. Hope functions 
as an energizing force. In addition, research indicates 
that hope may promote healing, facilitate coping, 
and enhance quality of life (Nekolaichuk, Jevne, & 
Maguire, 1999). 

Kiibler-Ross (1969), in her classic study of dying pa- 
tients, stressed the importance of hope. She suggested 
that, even though these patients could not hope for a 
cure, they could hope for additional time to live, to be 
with loved ones, for freedom from pain, or for a peace- 
ful death with dignity. She found hope to be a satis- 
faction unto itself, whether or not it was fulfilled. She 
stated, "If a patient stops expressing hope, it is usually 
a sign of imminent death" (p. 140). 

Researchers in the field of psychoneuroimmunology 
have found that the attitudes we have and the emo- 
tions we experience have a definite effect on the body. 
An optimistic feeling of hope is not just a mental state. 
Hope and optimism produce positive physical changes 
in the body that can influence the immune system and 
the functioning of specific body organs. The medical 
literature abounds with countless examples of individ- 
uals with terminal conditions who suddenly improve 
when they find something to live for. Conversely, there 
are also many accounts of patients whose conditions 
deteriorate when they lose hope. 


Love may be identified as a projection of one's own 
good feelings onto others. To love others, one must 
first experience love of self and then be able and will- 
ing to project that warmth and affectionate concern 
for others (Karren et al, 2006). 
Smucker (2001) states: 

Love, in its purest unconditional form, is probably life's 
most powerful force and our greatest spiritual need. 
Not only is it important to receive love, but equally 
important to give love to others. Thinking about and 
caring for the needs of others keeps us from being too 
absorbed with ourselves and our needs to the exclusion 
of others. We all have experienced the good feelings 
that come from caring for and loving others, (p. 10) 

Love may be a very important key in the healing 
process. Karren and associates (2006) state: 

People who become more loving and less fearful, 
who replace negative thoughts with the emotion of 

2338_Ch05_076-104.indd 93 

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love, are often able to achieve physical healing. Most 
of us are familiar with the emotional effects of love, 
the way love makes us feel inside. But . . . true love — a 
love that is patient, trusting, protecting, optimistic, 
and kind — has actual physical effects on the body, 
too. (p. 466) 

Some researchers suggest that love has a positive ef- 
fect on the immune system. This has been shown to 
be true in adults and children, and also in animals (Fox 
& Fox, 1988; Ornish, 1998). The giving and receiving 
of love may also result in higher levels of endorphins, 
thereby contributing to a sense of euphoria and help- 
ing to reduce pain. 

In one long-term study, researchers Werner and 
Smith (1992) studied children who were reared in im- 
poverished environments. Their homes were troubled 
by discord, desertion, or divorce, or marred by parental 
alcoholism or mental illness. The subjects were studied 
at birth, childhood, adolescence, and adulthood. Two 
out of three of these high-risk children had developed 
serious learning and/or behavioral problems by age 10, 
or had a record of delinquencies, mental health prob- 
lems, or pregnancies by age 18. One fourth of them 
had developed "very serious" physical and psychoso- 
cial problems. By the time they reached adulthood, 
more than three fourths of them suffered from pro- 
found psychological and behavioral problems and even 
more were in poor physical health. But of particular 
interest to the researchers were the 15 to 20 percent 
who remained resilient and well despite their impov- 
erished and difficult existence. The children who re- 
mained resilient and well had experienced a warm and 
loving relationship with another person during their 
first year of life, whereas the children who developed 
serious psychological and physical problems did not. 
This research indicates that the earlier people have 
the benefit of a strong, loving relationship, the better 
they seem able to resist the effects of a deleterious 


Karren and associates (2006) state, "Essential to a spir- 
itual nature is forgiveness — the ability to release from 
the mind all the past hurts and failures, all sense of 
guilt and loss" (p. 434). Feelings of bitterness and re- 
sentment take a physical toll on an individual by gen- 
erating stress hormones, which, maintained for long 
periods, can have a detrimental effect on a person's 
health. Forgiveness enables a person to cast off resent- 
ment and begin the pathway to healing. 

Forgiveness is not easy. Individuals often have great 
difficulty when called upon to forgive others and even 

greater difficulty in attempting to forgive themselves. 
Many people carry throughout their lives a sense of 
guilt for having committed a mistake for which they 
do not believe they have been forgiven or for which 
they have not forgiven themselves. 

To forgive is not necessarily to condone or excuse 
one's own or someone else's inappropriate behavior. 
Karren and associates (2006) suggest that forgiveness is 

... an attitude that implies that you are willing to ac- 
cept responsibility for your perceptions, realizing that 
your perceptions are a choice and not an objective 
fact; a decision to see beyond the limits of another's 
personality, and to gradually transform yourself from 
being a helpless victim of your circumstances to be- 
ing a powerful and loving co-creator of your reality, 
(pp. 434-435) 

Holding on to grievances causes pain, suffering, and 
conflict. Forgiveness (of self and others) is a gift to 
oneself. It offers freedom and peace of mind. 

It is important for nurses to be able to assess the 
spiritual needs of their clients. Nurses need not serve 
the role of professional counselor or spiritual guide, 
but because of the closeness of their relationship with 
clients, nurses may be the part of the health-care team 
to whom clients may reveal the most intimate details 
of their lives. Smucker (2001) states: 

Just as answering a patient's question honestly and 
with accurate information and responding to his 
needs in a timely and sensitive manner communicates 
caring, so also does high-quality professional nursing 
care reach beyond the physical body or the illness to 
that part of the person where identity, self- worth, and 
spirit lie. In this sense, good nursing care is also good 
spiritual care. (pp. 11-12) 


Religion is one way in which an individual's spirituality 
may be expressed. There are more than 6,500 religions 
in the world (Bronson, 2005). Some individuals seek 
out various religions in an attempt to find answers to 
fundamental questions that they have about life, and 




A set of beliefs, values, rites, and rituals adopted 
by a group of people. The practices are usually 
grounded in the teachings of a spiritual leader. 

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indeed, about their very existence. Others, although 
they may regard themselves as spiritual, choose not to 
affiliate with an organized religious group. In either 
situation, however, it is inevitable that questions re- 
lated to life and the human condition arise during the 
progression of spiritual maturation. 

Brodd (2003) suggests that all religious traditions 
manifest seven dimensions: experiential, mythic, doctri- 
nal, ethical, ritual, social, and material. He explains that 
these seven dimensions are intertwined and complemen- 
tary and, depending on the particular religion, certain 
dimensions are emphasized more than others. For ex- 
ample, Zen Buddhism has a strong experiential dimen- 
sion, but says little about doctrines. Roman Catholicism 
is strong in both ritual and doctrine. The social dimen- 
sion is a significant aspect of religion, as it provides a 
sense of community, of belonging to a group such as a 
parish or a congregation, which is empowering for some 

Affiliation with a religious group has been shown to 
be a health-enhancing endeavor (Karren et al, 2006). A 
number of studies have been conducted that indicate a 
correlation between religious faith/church attendance 
and increased chance of survival following serious ill- 
ness, less depression and other mental illness, longer 
life, and overall better physical and mental health. In 
an extensive review of the literature, Maryland psy- 
chologist John Gartner (1998) found that individuals 
with a religious commitment had lower suicide rates, 
lower drug use and abuse, less juvenile delinquency, 
lower divorce rates, and improved mental illness out- 

It is not known how religious participation pro- 
tects health and promotes well-being. Some church- 
es actively promote healthy lifestyles and discourage 
behavior that would be harmful to health or inter- 
fere with treatment of disease. But some research- 
ers believe that the strong social support network 
found in churches may be the most important force 
in boosting the health and well-being of their mem- 
bers. More so than merely an affiliation, however, it 
is regular church attendance and participation that 
appear to be the key factors. 



It is important for nurses to consider spiritual and 
religious needs when planning care for their clients. 
The Joint Commission requires that nurses address 
the psychosocial, spiritual, and cultural variables that 
influence the perception of illness. Dossey (1998) has 

developed a spiritual assessment tool (Box 5-3) about 
which she states: 

The Spiritual Assessment Tool provides reflective 
questions for assessing, evaluating, and increas- 
ing awareness of spirituality in patients and their 
significant others. The tool's reflective questions can 
facilitate healing because they stimulate spontaneous, 
independent, meaningful initiatives to improve the 
patient's capacity for recovery and healing, (p. 45) 

Diagnoses/Outcome Identification/ 

Nursing diagnoses that may be used when address- 
ing spiritual and religious needs of clients include the 

• Risk for Spiritual Distress 

• Spiritual Distress 

• Readiness for Enhanced Spiritual Well-Being 

• Risk for Impaired Religiosity 

• Impaired Religiosity 

• Readiness for Enhanced Religiosity 

The following outcomes may be used as guidelines 
for care and to evaluate effectiveness of the nursing 

Client Will: 

1 . Identify meaning and purpose in life that reinforce 
hope, peace, and contentment. 

2 . Verbalize acceptance of self as worthwhile human 

3 . Accept and incorporate change into life in a healthy 

4. Express understanding of relationship between dif- 
ficulties in current life situation and interruption in 
previous religious beliefs and activities. 

5. Discuss beliefs and values about spiritual and reli- 
gious issues. 

6. Express desire and ability to participate in beliefs 
and activities of desired religion. 


NANDA International (2009) information related to 
the diagnoses Risk for Spiritual Distress and Risk for 
Impaired Religiosity is provided in the subsections 
that follow. 

Risk for Spiritual Distress 

Definition. At risk for an impaired ability to ex- 
perience and integrate meaning and purpose in life 
through a person's connectedness with self, others, art, 

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Box 5-3 Spiritual Assessment Tool 

The following reflective questions may assist you in assess- 
ing, evaluating, and increasing awareness of spirituality in 
yourself and others. 

Meaning and Purpose 

These questions assess a person's ability to seek meaning 
and falfillment in life, manifest hope, and accept ambiguity 
and uncertainty. 

• What gives your life meaning? 

• Do you have a sense of purpose in life? 

• Does your illness interfere with your life goals? 

• Why do you want to get well? 

• How hopeful are you about obtaining a better degree of 

• Do you feel that you have a responsibility in maintaining 
your health? 

• Will you be able to make changes in your life to maintain 
your health? 

• Are you motivated to get well? 

• What is the most important or powerful thing in your 

Inner Strengths 

These questions assess a person's ability to manifest joy and 
recognize strengths, choices, goals, and faith. 

• What brings you joy and peace in your life? 

• What can you do to feel alive and full of spirit? 

• What traits do you like about yourself? 

• What are your personal strengths? 

• What choices are available to you to enhance your 

• What life goals have you set for yourself? 

• Do you think that stress in any way caused your 

• How aware were you of your body before 
became sick? 

• What do you believe in? 

• Is faith important in your life? 

• How has your illness influenced your faith? 

• Does faith play a role in recognizing your health? 



These questions assess a person's positive self-concept, self- 
esteem, and sense of self; sense of belonging in the world 
with others; capacity to pursue personal interests; and abil- 
ity to demonstrate love of self and self- forgiveness. 

How do you feel about yourself right now? 

How do you feel when you have a true 


Do you pursue things of personal interest? 

What do you do to show love for yourself? 

Can you forgive yourself? 

What do you do to heal your spirit? 


These questions assess a person's ability to connect in life- 
giving ways with family, friends, and social groups and to 
engage in the forgiveness of others. 

Who are the significant people in your life? 

Do you have friends or family in town who are available 

to help you? 

Who are the people to whom you are closest? 

Do you belong to any groups? 

Can you ask people for help when you need it? 

Can you share your feelings with others? 

What are some of the most loving things that others 

have done for you? 

What are the loving things that you do for other people? 

Are you able to forgive others? 

These questions assess a person's capacity for finding mean- 
ng in worship or religious activities, and a connectedness 
with a divinity. 

Is worship important to you? 

What do you consider the most significant act of wor- 
ship in your life? 

Do you participate in any religious activities? 
Do you believe in God or a higher power? 
Do you think that prayer is powerful? 
Have you ever tried to empty your mind of all thoughts 
to see what the experience might be? 
Do you use relaxation or imagery skills? 
Do you meditate? 
Do you pray? 
What is your prayer? 
How are your prayers answered? 
Do you have a sense of belonging in this world? 

These questions assess a person's ability to experience a 
sense of connection with life and nature, an awareness of 
the effects of the environment on life and well-being, and a 
capacity or concern for the health of the environment. 

• Do you ever feel a connection with the world or 

• How does your environment have an impact on your 
state of well-being? 

• What are your environmental stressors at work and at 

• What strategies reduce your environmental stressors? 

• Do you have any concerns for the state of your immedi- 
ate environment? 

• Are you involved with environmental issues such as recy- 
cling environmental resources at home, work, or in your 

• Are you concerned about the survival of the planet? 

From: Dossey, B.M. (1998). Holistic modalities and healing moments. American Journal of Nursing, 98(6), 44-47. With 

Sources: Burkhardt, M.A. (1989). Spirituality: An analysis of the concept. Holistic Nursing Practice, 3(3), 69-77; Dossey, B.M., 

et al (Eds.). (1995). Holistic nursing: A handbook for practice (2nd ed.). Gaithersburg, MD: Aspen. 

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music, literature, nature, and/or a power greater than 

Risk Factors 

Physical: Physical/chronic illness; substance abuse 

Psychosocial: Low self-esteem; depression; anxiety; 
stress; poor relationships; separated from support 
systems; blocks to experiencing love; inability to 
forgive; loss; racial/cultural conflict; change in reli- 
gious rituals; change in spiritual practices 

Developmental: Life changes 

Environmental: Environmental changes; natural dis- 

Risk for Impaired Religiosity 

Definition. At risk for an impaired ability to exercise 
reliance on religious beliefs and/or participate in ritu- 
als of a particular faith tradition. 

Risk Factors 

Physical: Illness/hospitalization; pain 

Psychological: Ineffective support/coping/caregiving; 
depression; lack of security 

Sociocultural: Lack of social interaction; cultural bar- 
rier to practicing religion; social isolation 

Spiritual: Suffering 

Environmental: Lack of transportation; environmen- 
tal barriers to practicing religion 

Developmental: Life transitions 

A plan of care addressing client's spiritual/religious 
needs is presented in Table 5-3. Selected nursing di- 
agnoses are presented, along with appropriate nursing 
interventions and rationales for each. 


Evaluation of nursing actions is directed at achieve- 
ment of the established outcomes. Part of the evalu- 
ation process is continuous reassessment to ensure 
that the selected actions are appropriate, and the goals 
and outcomes are realistic. Including the family and 
extended support systems in the evaluation process is 
essential if spiritual and religious implications of nurs- 
ing care are to be measured. Modifications to the plan 
of care are made as the need is determined. 


Culture encompasses shared patterns of belief, feel- 
ing, and knowledge that guide people's conduct and 
are passed down from generation to generation. 

Ethnic groups are bound together by a shared 

Cultural groups differ in terms of communication, 
space, social organization, time, environmental 
control, and biological variations. 
Northern European Americans are the descendents 
of the first immigrants to the United States and 
make up the current dominant cultural group. They 
value punctuality, a responsible work ethic, and a 
healthy lifestyle. 

African Americans trace their roots in the United 
States to the days of slavery. Most have large sup- 
port systems and a strong religious orientation. 
Many have assimilated into and have many of the 
same characteristics as the dominant culture. Some 
African Americans from the rural South may receive 
health care from a folk practitioner. 
Many Native Americans still live on reservations. They 
speak many different languages and dialects. They of- 
ten appear silent and reserved and many are uncom- 
fortable with touch and expressing emotions. Health 
care may be delivered by a healer called a shaman. 
Asian American languages are very diverse. Touch- 
ing during communication has historically been 
considered unacceptable. Individuals may have dif- 
ficulty expressing emotions and appear cold and 
aloof. Family loyalty is emphasized. Psychiatric ill- 
ness is viewed as behavior that is out of control and 
brings shame on the family. 

The common language of Latino Americans is Span- 
ish. Large family groups are important, and touch is 
a common form of communication. The predomi- 
nant religion is Roman Catholicism, and the church 
is often a source of strength in times of crisis. Health 
care may be delivered by a folk healer called a curan- 
dero, who uses various forms of treatment to restore 
the body to a balanced state. 

Western European Americans have their origins 
in Italy, France, and Greece. They are warm and 
expressive and use touch as a common form of 
communication. The dominant religion is Roman 
Catholicism for the Italians and French, and Greek 
Orthodoxy for the Greeks. Most Western European 
Americans follow the health practices of the domi- 
nant culture, but some folk beliefs and superstitions 

I Arab Americans trace their ancestry and traditions 
to the nomadic desert tribes of the Arabian Peninsula. 
Arabic is the official language of the Arab world, 
and the dominant religion is Islam. Mental illness is 
considered a social stigma, and symptoms are often 

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Ta b 1 e 5-3 Care Plan for the Client With Spiritual and Religious Needs* 


RELATED TO: Life changes; environmental changes; stress; anxiety; depression 

EVIDENCED BY: Questioning meaning of life and own existence; inner conflict about personal beliefs 
and values 

Outcome Criteria 

Nursing Interventions 


Client will identify 
meaning and purpose in 
life that reinforce hope, 
peace, contentment, and 




Assess current situation. 

Listen to client's expressions of 
anger, concern, self-blame. 

Note reason for living and whether it 
is directly related to situation. 

1-8. Thorough assessment is necessary to 

develop an accurate care plan for the client. 


Determine client's religious/spiritual 
orientation, current involvement, 
presence of conflicts, especially in 
current circumstances. 


Assess sense of self-concept, worth, 
ability to enter into loving relation- 


Observe behavior indicative of poor 
relationships with others. 


Determine support systems available 
to and used by client and significant 


Assess substance use/abuse. 


Establish an environment that 
promotes free expression of feelings 
and concerns. 

9. Trust is the basis of a therapeutic nurse- 
client relationship. 


Have client identify and prioritize 
current/immediate needs. 

10. Helps client focus on what needs to be done 
and identify manageable steps to take. 


Discuss philosophical issues related 
to impact of current situation on 
spiritual beliefs and values. 

1 1 . Helps client to understand that certain life 
experiences can cause individuals to ques- 
tion personal values and that this response is 
not uncommon. 


Use therapeutic communication 
skills of reflection and Active- 

12. Helps client find own solutions to concerns. 


Review coping skills used and their 
effectiveness in current situation. 

1 3 . Identifies strengths to incorporate into plan 
and techniques that need revision. 


Provide a role model (e.g., nurse, 
individual experiencing similar 

14. Sharing of experiences and hope assists cli- 
ent to deal with reality. 


Suggest use of journaling. 

15. Journaling can assist in clarifying beliefs 
and values and in recognizing and resolving 
feelings about current life situation. 


Discuss client's interest in the arts, 
music, literature. 

16. Provides insight into meaning of these 
issues and how they are integrated into an 
individual's life. 


Role-play new coping techniques. 
Discuss possibilities of taking classes, 
becoming involved in discussion 
groups, cultural activities of their 

17. These activities will help to enhance inte- 
gration of new skills and necessary changes 
in client's lifestyle 

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Table 5-3 Care Plan for the Client With Spiritual and Religious Needs* (Continued) 

Outcome Criteria 

Nursing Interventions 


18. Refer client to appropriate 
resources for help. 

18. Client may require additional assistance 
with an individual who specializes in these 
types of concerns. 


RELATED TO: Suffering; depression; illness; life transitions 

EVIDENCED BY: Concerns about relationship with deity; unable to participate in usual religious 
practices; anger toward God 

Outcome Criteria 

Nursing Interventions 


Client will express 
achievement of support 
and personal satisfaction 
from spiritual/religious 

1. Assess current situation (e.g., ill- 
ness, hospitalization, prognosis of 
death, presence of support systems, 
financial concerns). 

1 . This information identifies problems 
client is dealing with in the moment 
that are affecting desire to be involved 
with religious activities. 


2 . Listen nonjudgmen tally to client's 
expressions of anger and possible 
belief that illness/condition may be 
a result of lack of faith. 

2 . Individuals often blame themselves for 
what has happened and reject previous 
religious beliefs and/or God. 

3 . Determine client's usual religious/ 
spiritual beliefs, current involve- 
ment in specific church activities. 

3 . This is important background for estab- 
lishing a database. 

4. Note quality of relationships with 
significant others and friends. 

4. Individual may withdraw from others in 
relation to the stress of illness, pain, and 

5. Assess substance use/abuse. 

5. Individuals often turn to use of various 
substances in distress, and this can affect 
the ability to deal with problems in a 
positive manner. 

6. Develop nurse-client relationship 
in which individual can express 
feelings and concerns freely. 

6. Trust is the basis for a therapeutic 
nurse-client relationship. 

7. Use therapeutic communication 
skills of active listening, reflection, 
and I-messages. 

7. Helps client to find own solutions to 
problems and concerns and promotes 
sense of control. 

8. Be accepting and nonjudgmental 
when client expresses anger and 
bitterness toward God. Stay with 
the client. 

8. The nurse's presence and nonjudgmen- 
tal attitude increase the client's feelings 
of self- worth and promote trust in the 

9. Encourage client to discuss previ- 
ous religious practices and how 
these practices provided support in 
the past. 

9. A nonjudgmental discussion of previous 
sources of support may help the client 
work through current rejection of them 
as potential sources of support. 

10. Allow the client to take the lead in 
initiating participation in religious 
activities, such as prayer. 

10. Client may be vulnerable in current 
situation and needs to be allowed to 
decide own resumption of these actions. 

1 1 . Contact spiritual leader of client's 
choice, if he or she requests. 

1 1 . These individuals serve to provide relief 
from spiritual distress and often can do 
so when other support persons cannot. 

*The interventions for this care plan were adapted from Doenges, Moorhouse, & Murr (2008). 

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The Jewish people came to the United States pre- 
dominantly from Spain, Portugal, Germany, and East- 
ern Europe. Four main Jewish religious groups exist 
today: Orthodox, Reform, Conservative, and Recon- 
structionist. The primary language is English. A high 
value is placed on education. Jewish Americans are 
very health conscious and practice preventive health 
care. The maintenance of one's mental health is con- 
sidered just as important as the maintenance of one's 
physical health. 

Culture-bound syndromes are clusters of physical 
and behavioral symptoms that are considered as ill- 
nesses or "afflictions" by specific cultures and recog- 
nized as such by the DSM-IV-TR. 

Spirituality is the human quality that gives meaning 
and sense of purpose to an individual's existence. 
Individuals possess a number of spiritual needs that 
include meaning and purpose in life, faith or trust 
in someone or something beyond themselves, hope, 
love, and forgiveness. 

Religion is a set of beliefs, values, rites, and rituals 
adopted by a group of people. 

Religion is one way in which an individual's spiritu- 
ality may be expressed. 

Affiliation with a religious group has been shown to 
be a health- enhancing endeavor. 
Nurses must consider cultural, spiritual, and reli- 
gious needs when planning care for their clients. 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 


1 . Miss Lee is an Asian American on the psychiatric unit. She tells the nurse, "I must have the hot 
ginger root for my headache. It is the only thing that will help." What meaning does the nurse 
attach to this statement by Miss Lee? 

a. She is being obstinate and wants control over her care. 

b. She believes that ginger root has magical qualities. 

c. She subscribes to the restoration of health through the balance of yin and yang. 

d. Asian Americans refuse to take traditional medicine for pain. 

2 . Miss Lee is an Asian American on the psychiatric unit. She says she is afraid that no one from her 
family will visit her. On what belief does Miss Lee base her statement? 

a. Many Asian Americans do not believe in hospitals. 

b. Many Asian Americans do not have close family support systems. 

c. Many Asian Americans believe the body will heal itself if left alone. 

d. Many Asian Americans view psychiatric problems as bringing shame to the family. 

3 . Joe, a Native American, appears at the community health clinic with an oozing stasis ulcer on his 
lower right leg. It is obviously infected, and he tells the nurse that the shaman has been treating it 
with herbs. The nurse determines that Joe needs emergency care, but Joe states he will not go to 
the emergency department (ED) unless the shaman is allowed to help treat him. How should the 
nurse handle this situation? 

a. Contact the shaman and have him meet them at the ED to consult with the attending physician. 

b. Tell Joe that the shaman is not allowed in the ED. 

c. Explain to Joe that the shaman is at fault for his leg being in the condition it is in now. 

d. Have the shaman try to talk Joe into going to the ED without him. 

4. Joe, a Native American, goes to the emergency department (ED) because he has an oozing stasis 
ulcer on his leg. He is accompanied by the tribal shaman, who has been treating Joe on the 
reservation. As a greeting, the physician extends his hand to the shaman, who lightly touches the 
physician's hand, then quickly moves away. How should the physician interpret this gesture? 

a. The shaman is snubbing the physician. 

b. The shaman is angry at Joe for wanting to go to the ED. 

c. The shaman does not believe in traditional medicine. 

d. The shaman does not feel comfortable with touch. 

5. Sarah is an African American woman who receives a visit from the psychiatric home health nurse. 
A referral for a mental health assessment was made by the public health nurse, who noticed that 
Sarah was becoming exceedingly withdrawn. When the psychiatric nurse arrives, Sarah says to her, 
"No one can help me. I was an evil person in my youth, and now I must pay" How might the nurse 
assess this statement? 

a. Sarah is having delusions of persecution. 

b. Some African Americans believe illness is God's punishment for their sins. 

c. Sarah is depressed and just wants to be left alone. 

d. African Americans do not believe in psychiatric help. 

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6. Sarah is an African American woman who lives in the rural South. She receives a visit from the 
public health nurse. Sarah says to the nurse, "Granny told me to eat a lot of poke greens and I 
would feel better." How should the nurse interpret this statement? 

a. Sarah's grandmother believes in the healing power of poke greens. 

b. Sarah believes everything her grandmother tells her. 

c. Sarah has been receiving health care from a "folk practitioner." 

d. Sarah is trying to determine if the nurse agrees with her grandmother. 

7. Frank is a Latino American who has an appointment at the community health center for 1:00 p.m. 
The nurse is angry when Frank shows up at 3:30 p.m. stating, "I was visiting with my brother." 
How must the nurse interpret this behavior? 

a. Frank is being passive- aggressive by showing up late. 

b. This is Frank's way of defying authority. 

c. Frank is a member of a cultural group that is oriented to the present time. 

d. Frank is a member of a cultural group that rejects traditional medicine. 

8. The nurse must give Frank, a Latino American, a physical examination. She tells him to remove 
his clothing and put on an examination gown. Frank refuses. How should the nurse interpret this 

a. Frank does not believe in taking orders from a woman. 

b. Frank is modest and embarrassed to remove his clothes. 

c. Frank does not understand why he must remove his clothes. 

d. Frank does not think he needs a physical examination. 

9. Maria is an Italian American who is in the hospital after having suffered a miscarriage at 

5 months' gestation. Her room is filled with relatives who have brought a variety of foods and 
gifts for Maria. They are all talking, seemingly at the same time, and some, including Maria, are 
crying. They repeatedly touch and hug Maria and each other. How should the nurse handle this 

a. Explain to the family that Maria needs her rest and they must all leave. 

b. Allow the family to remain and continue their activity as described, as long as they do not dis- 
turb other clients. 

c. Explain that Maria will not get over her loss if they keep bringing it up and causing her to cry 
so much. 

d. Call the family priest to come and take charge of this family situation. 

10. Maria is an Italian American who is in the hospital after having suffered a miscarriage at 5 months' 
gestation. Maria's mother says to the nurse, "If only Maria had told me she wanted the biscotti. I 
would have made them for her." What is the meaning behind Maria's mother's statement? 

a. Some Italian Americans believe a miscarriage can occur if a woman does not eat a food she 

b. Some Italian Americans think biscotti can prevent miscarriage. 

c. Maria's mother is taking the blame for Maria's miscarriage. 

d. Maria's mother believes the physician should have told Maria to eat biscotti. 

1 1 . Joe, who has come to the mental health clinic with symptoms of depression, says to the nurse, 
"My father is dying. I have always hated my father. He physically abused me when I was a child. 
We haven't spoken for many years. He wants to see me now, but I don't know if I want to see 
him." With which spiritual need is Joe struggling? 

a. Forgiveness 

b. Faith 

c. Hope 

d. Meaning and purpose in life 

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Chapter 5 



12. As a child, Joe was physically abused by his father. The father is now dying and has expressed a 
desire to see his son before he dies. Joe is depressed and says to the mental health nurse, "I'm so 
angry! Why did God have to give me a father like this? I feel cheated of a father! I've always been 
a good person. I deserved better. I hate God!" From this subjective data, which nursing diagnosis 
might the nurse apply to Joe? 

a. Readiness for enhanced religiosity 

b. Risk for impaired religiosity 

c. Readiness for enhanced spiritual well-being 

d. Spiritual distress 


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Unit Two 


Health Nursing 


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H A P T E R 

Relationship Development 
and Therapeutic 













concrete thinking 

intimate distance 






personal distance 



public distance 

unconditional positive regard 




social distance 



therapeutic communication 

therapeutic relationship 


After reading this chapter, the student will be able to: 

1. Describe the relevance and dynamics of a 
therapeutic nurse-client relationship. 

2. Identify goals of the nurse-client 

3. Identify and discuss essential conditions 
for a therapeutic relationship to occur. 

4. Describe the phases of relationship de- 
velopment and the tasks associated with 
each phase. 


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5. Identify types of preexisting conditions 
that influence the outcome of the commu- 
nication process. 

6. Define territoriality, density, and distance 
as components of the environment. 

7. Identify components of nonverbal 

8. Describe therapeutic and nontherapeutic 
verbal communication techniques. 

9. Describe active listening. 

10. Discuss therapeutic feedback. 


Please read the chapter and answer the following questions. 

1. When the nurse's verbal and nonverbal 
interactions are congruent, he or she is 
thought to be expressing which character- 
istic of therapeutic communication? 

2. During which phase of the nurse-client re- 
lationship do each of the following occur: 

a. The nurse may become angry and anx- 
ious in the presence of the client. 

b. A plan of action for dealing with stress 
is established. 

c. The nurse examines personal feelings 
about working with the client. 

d. The nurse and client establish goals of 

"What do you think you should do?" If 
the nurse makes this statement to a client, 
it is an example of what technique? Is it 
therapeutic or nontherapeutic? 
"Just hang in there. Everything will be 
all right." If the nurse makes this state- 
ment to a client, it is an example of 
what technique? Is it therapeutic or 


The nurse-client relationship is the foundation on 
which psychiatric nursing is established. It is a rela- 
tionship in which both participants must recognize 
each other as unique and important human beings. It 
is also a relationship in which mutual learning occurs. 
Peplau (1991) stated: 

Shall a nurse do things for a patient or can participant 
relationships be emphasized so that a nurse comes to 
do things with a patient as her share of an agenda of 
work to be accomplished in reaching a goal — health. 
It is likely that the nursing process is educative and 
therapeutic when nurse and patient can come to 
know and to respect each other, as persons who are 
alike, and yet, different, as persons who share in the 
solution of problems, (p. 9) 

Hays and Larson (1963) have stated, "To relate ther- 
apeutically with a patient, it is necessary for the nurse 
to understand his or her role and its relationship to the 
patient's illness." They describe the role of the nurse as 
providing the client with the opportunity to: 

• Identify and explore problems in relating to others. 

• Discover healthy ways of meeting emotional needs. 

• Experience a satisfying interpersonal relationship. 

The therapeutic interpersonal relationship is the proc- 
ess by which nurses provide care for clients in need of 
psychosocial intervention. Therapeutic use of self 'is the 
instrument for delivery of that care. Interpersonal com- 
munication techniques (both verbal and nonverbal) are 
the "tools" of psychosocial intervention. 

This chapter describes the phases of development 
of a therapeutic nurse-client relationship. Therapeutic 
use of self and techniques of interpersonal communi- 
cation are discussed. 


Travelbee (1971), who expanded on Peplau's theory of 
interpersonal relations in nursing, has stated that it is 
only when each individual in the interaction perceives 
the other as a human being that a relationship is pos- 
sible. She refers not to a nurse-client relationship, but 
rather to a human-to-human relationship, which she 
describes as a "mutually significant experience." That 

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Therapeutic Relationship 

An interaction between two people (usually a care- 
giver and a care receiver) in which input from both 
participants contributes to a climate of healing, 
growth promotion, and/or illness prevention. 

is, both the nurse and the recipient of care have needs 
met when each views the other as a unique human be- 
ing, not as "an illness," as "a room number," or as "all 
nurses" in general. 

Therapeutic relationships are goal oriented. Ideally, 
the nurse and client decide together what the goal of 
the relationship will be. Most often the goal is directed 
at learning and growth promotion in an effort to bring 
about some type of change in the client's life. In gener- 
al, the goal of a therapeutic relationship may be based 
on a problem-solving model. 



The client will demonstrate more adaptive coping 
strategies for dealing with (specific life situation). 


• Identify what is troubling the client at this time. 

• Encourage the client to discuss changes he or she 
would like to make. 

• Discuss with the client which changes are possible 
and which are not possible. 

• Have the client explore feelings about aspects that 
cannot be changed and alternative ways of coping 
more adaptively. 

• Discuss alternative strategies for creating changes 
the client desires to make. 

• Weigh the benefits and consequences of each alter- 

• Assist the client to select an alternative. 

• Encourage the client to implement the change. 

• Provide positive feedback for the client's attempts to 
create change. 

• Assist the client to evaluate outcomes of the change 
and make modifications as required. 

Therapeutic Use of Self 

Travelbee (1971) described the instrument for delivery 
of the process of interpersonal nursing as the therapeutic 

use of self, which she defined as "the ability to use one's 
personality consciously and in fall awareness in an at- 
tempt to establish relatedness and to structure nursing 

Use of the self in a therapeutic manner requires that 
the nurse have a great deal of self- awareness and self- 
understanding, having arrived at a philosophical belief 
about life, death, and the overall human condition. The 
nurse must understand that the ability and extent to 
which one can effectively help others in time of need 
is strongly influenced by this internal value system — a 
combination of intellect and emotions. 




Several characteristics that enhance the achievement of a 
therapeutic relationship have been identified. These con- 
cepts are highly significant to the use of self as the thera- 
peutic tool in interpersonal relationship development. 


Getting acquainted and establishing rapport is the pri- 
mary task in relationship development. Rapport im- 
plies special feelings on the part of both the client and 
the nurse based on acceptance, warmth, friendliness, 
common interest, a sense of trust, and a nonjudgmen- 
tal attitude. Establishing rapport may be accomplished 
by discussing non-health-related topics. Travelbee 
(1971) states: 

[To establish rapport] is to create a sense of har- 
mony based on knowledge and appreciation of each 
individual's uniqueness. It is the ability to be still and 
experience the other as a human being — to appreci- 
ate the unfolding of each personality one to the other. 
The ability to truly care for and about others is the 
core of rapport. 


To trust another, one must feel confidence in that per- 
son's presence, reliability, integrity, veracity, and sincere 
desire to provide assistance when requested. As identi- 
fied in Chapter 2, trust is the initial developmental task 
described by Erikson. If the task has not been achieved, 
this component of relationship development becomes 
more difficult. That is not to say that trust cannot be 
established, but only that additional time and patience 
may be required on the part of the nurse. 

It is imperative for the nurse to convey an aura of 
trustworthiness, which requires that he or she possess 

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a sense of self-confidence. Confidence in the self is de- 
rived from knowledge gained through achievement of 
personal and professional goals and the ability to inte- 
grate these roles and to function as a unified whole. 

Trust cannot be presumed; it must be earned. Trust- 
worthiness is demonstrated through nursing interven- 
tions that convey a sense of warmth and caring to the 
client. These interventions are initiated simply and 
concretely and directed toward activities that address 
the client's basic needs for physiological and psycho- 
logical safety and security. Many psychiatric clients 
experience concrete thinking, which focuses their 
thought processes on specifics rather than generalities 
and immediate issues rather than eventual outcomes. 
Examples of nursing interventions that would pro- 
mote trust in an individual who is thinking concretely 
include the following: 

• Providing a blanket when the client is cold 

• Providing food when the client is hungry 

• Keeping promises 

• Being honest (e.g., saying "I don't know the answer 
to your question, but I'll try to find out") and then 
following through 

• Simply and clearly providing reasons for certain 
policies, procedures, and rules 

• Providing a written, structured schedule of activities 

• Attending activities with the client if he or she is 
reluctant to go alone 

• Being consistent in adhering to unit guidelines 

• Taking the client's preferences, requests, and opin- 
ions into consideration when possible in decisions 
concerning his or her care 

• Ensuring confidentiality; providing reassurance 
that what is discussed will not be repeated outside 
the boundaries of the health-care team 

Trust is the basis of a therapeutic relationship. The 
nurse working in psychiatry must perfect the skills 
that foster the development of trust. Trust must be es- 
tablished in order for the nurse-client relationship to 
progress beyond the superficial level of tending to the 
client's immediate needs. 


To show respect is to believe in the dignity and worth 
of an individual regardless of his or her unacceptable 
behavior. The psychologist, Carl Rogers, called this 
unconditional positive regard (Raskin, Rogers, & 
Witty, 2011). The attitude is nonjudgmental, and the 
respect is unconditional in that it does not depend on 
the behavior of the client to meet certain standards. The 

nurse, in fact, may not approve of the client's lifestyle 
or pattern of behaving. However, with unconditional 
positive regard, the client is accepted and respected for 
no other reason than that he or she is considered to be 
a worthwhile and unique human being. 

Many psychiatric clients have very little self-respect 
because, as a result of their behavior, they have been 
rejected by others in the past. Recognition that they 
are being accepted and respected as unique individuals 
on an unconditional basis can serve to elevate feelings 
of self-worth and self-respect. The nurse can convey 
an attitude of respect by: 

• Calling the client by name (and title, if he or she 

• Spending time with the client 

• Allowing for sufficient time to answer the client's 
questions and concerns 

• Promoting an atmosphere of privacy during thera- 
peutic interactions with the client or when the cli- 
ent may be undergoing physical examination or 

• Always being open and honest with the client, even 
when the truth may be difficult to discuss 

• Taking the client's ideas, preferences, and opinions 
into consideration when planning care 

• Striving to understand the motivation behind the 
client's behavior, regardless of how unacceptable it 
may seem 


The concept of genuineness refers to the nurse's abil- 
ity to be open, honest, and, "real" in interactions with 
the client. To be "real" is to be aware of what one is 
experiencing internally and to allow the quality of this 
inner experiencing to be apparent in the therapeutic 
relationship (Raskin, Rogers, & Witty, 2011). When 
one is genuine, there is congruence between what is 
felt and what is being expressed. The nurse who pos- 
sesses the quality of genuineness responds to the client 
with truth and honesty, rather than with responses he 
or she may consider more "professional" or responses 
that merely reflect the "nursing role." 

Genuineness may call for a degree of self-disclosure 
on the part of the nurse. This is not to say that the 
nurse must disclose to the client everything he or 
she is feeling or all personal experiences that may re- 
late to what the client is going through. Indeed, care 
must be taken when using self- disclosure to avoid 
transposing the roles of nurse and client. When the 
nurse uses self-disclosure, a quality of "humanness" 

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is revealed to the client, creating a role for the client 
to model in similar situations. The client may then 
feel more comfortable revealing personal informa- 
tion to the nurse. 

Most individuals have an uncanny ability to detect 
other peoples' artificiality. When the nurse does not 
bring the quality of genuineness to the relationship, 
a reality base for trust cannot be established. These 
qualities are essential if the actualizing potential of the 
client is to be realized and for change and growth to 
occur (Raskin, Rogers, & Witty, 2011). 


Empathy is a process wherein an individual is able 
to see beyond outward behavior and sense accurately 
another's inner experience at a given point in time 
(Travelbee, 1971). With empathy, the nurse can accu- 
rately perceive and understand the meaning and rel- 
evance of the client's thoughts and feelings. The nurse 
must also be able to communicate this perception 
to the client. This is done by attempting to translate 
words and behaviors into feelings. 

It is not uncommon for the concept of empathy to 
be confused with that of sympathy. The major dif- 
ference is that with empathy the nurse "accurately 
perceives or understands" what the client is feeling 
and encourages the client to explore these feelings. 
With sympathy, the nurse actually "shares" what the 
client is feeling, and experiences a need to alleviate 

Empathy is considered to be one of the most impor- 
tant characteristics of a therapeutic relationship. Ac- 
curate empathetic perceptions on the part of the nurse 
assist the client to identify feelings that may have been 
suppressed or denied. Positive emotions are generated 
as the client realizes that he or she is truly understood 
by another. As the feelings surface and are explored, 
the client learns aspects about self of which he or she 
may have been unaware. This contributes to the proc- 
ess of personal identification and the promotion of 
positive self-concept. 

With empathy, while understanding the client's 
thoughts and feelings, the nurse is able to maintain 
sufficient objectivity to allow the client to achieve 
problem resolution with minimal assistance. With 
sympathy, the nurse actually feels what the client is 
feeling, objectivity is lost, and the nurse may become 
focused on relief of personal distress rather than on 
helping the client resolve the problem at hand. The 
following is an example of an empathetic and sympa- 
thetic response to the same situation. 


Situation: BJ is a client on the psychiatric unit with a 
diagnosis of Dysthymic Disorder. She is 5'5" tall and 
weighs 295 pounds. BJ has been overweight all her life. 
She is single, has no close friends, and has never had 
an intimate relationship with another person. It is her 
first day on the unit, and she is refusing to come out of 
her room. When she appeared for lunch in the dining 
room following admission, she was embarrassed when 
several of the other clients laughed out loud and call 
her "fatso." 

Sympathetic response: Nurse: "I can certainly iden- 
tify with what you are feeling. I've been overweight 
most of my life, too. I just get so angry when people act 
like that. They are so insensitive! It's just so typical of 
skinny people to act that way. You have a right to want 
to stay away from them. We'll just see how loud they 
laugh when you get to choose what movie is shown on 
the unit after dinner tonight." 

Empathetic response: Nurse: "You feel angry and em- 
barrassed by what happened at lunch today." As tears 
fill BJ's eyes, the nurse encourages her to cry if she feels 
like it and to express her anger at the situation. She stays 
with BJ, but does not dwell on her own feelings about 
what happened. Instead she focuses on BJ and what the 
client perceives are her most immediate needs. 


Psychiatric nurses use interpersonal relationship de- 
velopment as the primary intervention with clients 
in various psychiatric/mental health settings. This is 
congruent with Peplau's (1962) identification of coun- 
seling as the major subrole of nursing in psychiatry. 
Sullivan (1953), from whom Peplau patterned her own 
interpersonal theory of nursing, strongly believed that 
all emotional problems were closely related to difficul- 
ties with interpersonal relationships. With this concept 
in mind, this role of the nurse in psychiatry becomes 
especially meaningful and purposeful. It becomes an 
integral part of the total therapeutic regimen. 

The therapeutic interpersonal relationship is the 
means by which the nursing process is implemented. 
Through the relationship, problems are identified and 
resolution is sought. Tasks of the relationship have 
been categorized into four phases: 

1 . Preinteraction phase 

2 . Orientation (introductory) phase 

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3. Working phase 

4. Termination phase 

Although each phase is presented as specific and dis- 
tinct from the others, there may be some overlapping 
of tasks, particularly when the interaction is limited. 
The major goals during each phase of the nurse-client 
relationship are listed in Table 6-1. 

The Preinteraction Phase 

The preinteraction phase involves preparation for the 
first encounter with the client. Tasks include: 

• Obtaining available information about the client 
from his or her chart, significant others, or other 
health team members. From this information, the 
initial assessment is begun. This initial information 
may also allow the nurse to become aware of per- 
sonal responses to knowledge about the client. 

• Examining one's feelings, fears, and anxieties about 
working with a particular client. For example, the 
nurse may have been reared in an alcoholic family 
and have ambivalent feelings about caring for a cli- 
ent who is alcohol dependent. All individuals bring 
attitudes and feelings from prior experiences to the 
clinical setting. The nurse needs to be aware of how 
these preconceptions may affect his or her ability to 
care for individual clients. 

The Orientation (Introductory) Phase 

During the orientation phase, the nurse and client be- 
come acquainted. Tasks include: 

• Creating an environment for the establishment of 
trust and rapport 

• Establishing a contract for intervention that details 
the expectations and responsibilities of both the 
nurse and client 

• Gathering assessment information to build a strong 
client database 

Table 6-1 

Phases of Relationship 
Development and Major 
Nursing Goals 



1. Preinteraction 

2. Orientation (introductory) 

3. Working 

4. Termination 

Explore self-perceptions. 
Establish trust and formulate 

contract for intervention. 
Promote client change. 
Evaluate goal attainment and 

ensure therapeutic closure. 

• Identifying the client's strengths and limitations 

• Formulating nursing diagnoses 

• Setting goals that are mutually agreeable to the 
nurse and client 

• Developing a plan of action that is realistic for meet- 
ing the established goals 

• Exploring feelings of both the client and nurse 

Introductions often are uncomfortable, and the par- 
ticipants may experience some anxiety until a degree of 
rapport has been established. Interactions may remain 
on a superficial level until anxiety subsides. Several in- 
teractions may be required to fulfill the tasks associ- 
ated with this phase. 

The Working Phase 

The therapeutic work of the relationship is accom- 
plished during this phase. Tasks include: 

• Maintaining the trust and rapport that was estab- 
lished during the orientation phase 

• Promoting the client's insight and perception of 

• Problem-solving using the model presented earlier 
in this chapter 

• Overcoming resistance behaviors on the part of 
the client as the level of anxiety rises in response to 
discussion of painful issues 

• Continuously evaluating progress toward goal at- 

Transference and Countertransference 

Transference and countertransference are common 
phenomena that often arise during the course of a ther- 
apeutic relationship. 


Transference occurs when the client unconscious- 
ly attributes (or "transfers") to the nurse feelings 
and behavioral predispositions formed toward a per- 
son from his or her past (Sadock & Sadock, 2007). 
These feelings toward the nurse may be triggered 
by something about the nurse's appearance or 
personality that reminds the client of the person. 
Transference can interfere with the therapeutic in- 
teraction when the feelings being expressed include 
anger and hostility. Anger toward the nurse can be 
manifested by uncooperativeness and resistance to 
the therapy. 

Transference can also take the form of overwhelm- 
ing affection for the nurse or excessive dependency on 

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the nurse. The nurse is overvalued and the client forms 
unrealistic expectations of the nurse. When the nurse is 
unable to fulfill those expectations or meet the excessive 
dependency needs, the client may become angry and 

Interventions for Transference. Hilz (2008) states: 

In cases of transference, the relationship does not 
usually need to be terminated, except when the 
transference poses a serious barrier to therapy or 
safely. The nurse should work with the patient in 
sorting out the past from the present, and assist the 
patient into identifying the transference and reassign 
a new and more appropriate meaning to the current 
nurse-patient relationship. The goal is to guide the 
patient to independence by teaching them to assume 
responsibility for their own behaviors, feelings, and 
thoughts, and to assign the correct meanings to the 
relationships based on present circumstances instead 
of the past. 

Coun tertran sferen ce 

Countertransference refers to the nurse's behavioral 
and emotional response to the client. These responses 
may be related to unresolved feelings toward signifi- 
cant others from the nurse's past, or they may be gen- 
erated in response to transference feelings on the part 
of the client. It is not easy to refrain from becoming 
angry when the client is consistently antagonistic, to 
feel flattered when showered with affection and atten- 
tion by the client, or even to feel quite powerful when 
the client exhibits excessive dependency on the nurse. 
These feelings can interfere with the therapeutic re- 
lationship when they initiate the following types of 

• The nurse overidentifies with the client's feelings 
because they remind him or her of problems from 
the nurse's past or present. 

• The nurse and client develop a social or personal 

• The nurse begins to give advice or attempts to "res- 
cue" the client. 

• The nurse encourages and promotes the client's 

• The nurse's anger engenders feelings of disgust to- 
ward the client. 

• The nurse feels anxious and uneasy in the presence 
of the client. 

• The nurse is bored and apathetic in sessions with 
the client. 

• The nurse has difficulty setting limits on the client's 

• The nurse defends the client's behavior to other 
staff members. 

The nurse may be completely unaware or only mini- 
mally aware of the countertransference as it is occurring 
(Hilz, 2008). 

Interventions for Countertransference. Hilz (2008) 

The relationship usually should not be terminated in 
the presence of countertransference. Rather, the nurse 
or staff member experiencing the countertrans- 
ference should be supportively assisted by other 
staff members to identify his or her feelings and 
behaviors and recognize the occurrence of the 
phenomenon. It may be helpful to have evaluative 
sessions with the nurse after his or her encounter 
with the patient, in which both the nurse and other 
staff members (who are observing the interactions) 
discuss and compare the exhibited behaviors in the 

The Termination Phase 

Termination of the relationship may occur for a vari- 
ety of reasons: the mutually agreed-on goals may have 
been reached; the client may be discharged from the 
hospital; or, in the case of a student nurse, it may be 
the end of a clinical rotation. Termination can be a dif- 
ficult phase for both the client and nurse. The main 
task involves bringing a therapeutic conclusion to the 
relationship. This occurs when: 

• Progress has been made toward attainment of mu- 
tually set goals. 

• A plan for continuing care or for assistance during 
stressful life experiences is mutually established by 
the nurse and client. 

• Feelings about termination of the relationship are 
recognized and explored. Both the nurse and cli- 
ent may experience feelings of sadness and loss. The 
nurse should share his or her feelings with the client. 
Through these interactions, the client learns that it 
is acceptable to have these feelings at a time of sepa- 
ration. Through this knowledge, the client experi- 
ences growth during the process of termination. 

NOTE: When the client feels sadness and loss, 
behaviors to delay termination may become evi- 
dent. If the nurse experiences the same feelings, 
he or she may allow the client's behaviors to delay 
termination. For therapeutic closure, the nurse 
must establish the reality of the separation and 
resist being manipulated into repeated delays by 
the client. 

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A boundary indicates a border or a limit. It determines 
the extent of acceptable limits. Many types of bounda- 
ries exist. Examples include the following: 

• Material boundaries: These are physical properties 
that can be seen, such as fences that border land. 

• Social boundaries: These are established within a 
culture and define how individuals are expected to 
behave in social situations. 

• Personal boundaries: These are boundaries that 
individuals define for themselves. These include 
physical distance boundaries, or just how close in- 
dividuals will allow others to invade their physical 
space, and emotional boundaries, or how much in- 
dividuals choose to disclose of their most private 
and intimate selves to others. 

• Professional boundaries: These boundaries limit 
and outline expectations for appropriate profession- 
al relationships with clients. They separate thera- 
peutic behavior from any other behavior that, well 
intentioned or not, could lessen the benefit of care 
to clients (College and Association of Registered 
Nurses of Alberta [CARNA] , 2005). 

Concerns regarding professional boundaries are 
commonly related to the following issues: 

1. Self-disclosure: Self- disclosure on the part of the 
nurse may be appropriate when it is judged that the 
information may therapeutically benefit the client. 
It should never be undertaken for the purpose of 
meeting the nurse's needs. 

2. Gift giving: Individuals who are receiving care of- 
ten feel indebted toward health-care providers. And, 
indeed, gift giving may be part of the therapeutic 
process for people who receive care (CARNA, 2005). 
Cultural belief and values may also enter into the 
decision of whether to accept a gift from a client. In 
some cultures, failure to do so would be interpreted 
as an insult. Accepting financial gifts is never appro- 
priate, but in some instances nurses may be permit- 
ted to suggest instead a donation to a charity of the 
client's choice. If acceptance of a small gift of grati- 
tude is deemed appropriate, the nurse may choose 
to share it with other staff members who have been 
involved in the client's care. In all instances, nurses 
should exercise professional judgment when decid- 
ing whether to accept a gift from a client. Attention 
should be given to what the gift giving means to the 
client, as well as to institutional policy, the American 

Nurses Association (ANA) Code of Ethics for Nurses, 
and the ANA Scope and Standards of Practice. 

3. Touch: Nursing by its very nature involves 
touching clients. Touching is required to per- 
form the many therapeutic procedures involved 
in the physical care of clients. Caring touch is 
the touching of clients when there is no physi- 
cal need (Registered Nurses Association of British 
Columbia [RNABC], 2003). Caring touch often 
provides comfort or encouragement, and, when 
it is used appropriately, it can have a therapeutic 
effect on the client. However, certain vulnerable 
clients may misinterpret the meaning of touch. 
Certain cultures, such as Native Americans and 
Asian Americans, are often uncomfortable with 
touch. The nurse must be sensitive to these cul- 
tural nuances and aware when touch is crossing a 
personal boundary. Additionally, clients who are 
experiencing high levels of anxiety or suspicious 
or psychotic behaviors may interpret touch as ag- 
gressive. These are times when touch should be 
avoided or considered with extreme caution. 

4. Friendship or romantic association: When a 
nurse is acquainted with a client, the relationship 
must move from one of a personal nature to a pro- 
fessional one. If the nurse is unable to accomplish 
this separation, he or she should withdraw from 
the nurse- client relationship. Likewise, nurses must 
guard against personal relationships developing as 
a result of the nurse-client relationship. Romantic, 
sexual, or similar personal relationships are never 
appropriate between nurse and client. 

Certain warning signs exist that indicate that profes- 
sional boundaries of the nurse-client relationship may 
be in jeopardy. Some of these include the following 
(Coltrane & Pugh, 1978): 

• Favoring a client's care over that of another 

• Keeping secrets with a client 

• Changing dress style for working with a particular 

• Swapping client assignments to care for a particular 

• Giving special attention or treatment to one client 
over others 

• Spending free time with a client 

• Frequently thinking about the client when away 
from work 

• Sharing personal information or work concerns 
with the client 

• Receiving of gifts from or continued contact/ 
communication with the client after discharge 

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Boundary crossings can threaten the integrity 
of the nurse-client relationship. Nurses must gain 
self-awareness and insight to be able to recognize 
when professional integrity is being compromised. 
Peternelj -Taylor and Yonge (2003) state: 

The nursing profession needs nurses who have the 
ability to make decisions about boundaries based on 
the best interests of the clients in their care. This 
requires nurses to reflect on their knowledge and ex- 
periences, on how they think and how they feel, and 
not simply to buy blindly into a framework that says, 
"do this," "don't do that." (p. 65) 


It has been said that individuals "cannot not communi- 
cate." Every word that is spoken and every movement 
that is made gives a message to someone. Interpersonal 
communication is a transaction between the sender 
and the receiver. In the transactional model of com- 
munication, both participants simultaneously perceive 
each other, listen to each other, and are mutually in- 
volved in creating meaning in a relationship. 

The Impact of Preexisting Conditions 

In all interpersonal transactions, both the sender and 
receiver bring certain preexisting conditions to the ex- 
change that influence both the intended message and 
the way in which it is interpreted. Examples of these 
conditions include one's value system, internalized at- 
titudes and beliefs, culture or religion, social status, 
gender, background knowledge and experience, and 
age or developmental level. The type of environment 
in which the communication takes place also may in- 
fluence the outcome of the transaction. 

Values, Attitudes, and Beliefs 

Values, attitudes, and beliefs are learned ways of think- 
ing. Children generally adopt the value systems and 
internalize the attitudes and beliefs of their parents. 


Children may retain this way of thinking into adult- 
hood or develop a different set of attitudes and values 
as they mature. 

Values, attitudes, and beliefs can influence commu- 
nication in numerous ways. For example, prejudice can 
be expressed verbally through negative stereotyping. 

One's value system may be communicated with be- 
haviors that are more symbolic in nature. For example, 
an individual who values youth may dress and behave 
in a manner that is characteristic of one who is much 
younger. Persons who value freedom and the American 
way of life may fly the U.S. flag in front of their homes 
each day. In each of these situations, a message is being 

Culture or Religion 

Communication has its roots in culture. Cultural mo- 
res, norms, ideas, and customs provide the basis for 
our way of thinking. Cultural values are learned and 
differ from society to society. For example, in some 
European countries (e.g., Italy, Spain, and France), 
men may greet each other with hugs and kisses. These 
behaviors are appropriate in those cultures, but they 
would communicate a different message in the United 
States or England. 

Religion also can influence communication. Priests 
and ministers who wear clerical collars publicly com- 
municate their mission in life. The collar also may 
influence the way in which others relate to them, ei- 
ther positively or negatively. Other symbolic gestures, 
such as wearing a cross around the neck or hanging a 
crucifix on the wall, also communicate an individual's 
religious beliefs. 

Social Status 

Studies of nonverbal indicators of social status or power 
have suggested that high-status persons are associated 
with gestures that communicate their higher-power 
position. For example, they use less eye contact, have 
a more relaxed posture, use louder voice pitch, place 
hands on hips more frequently, are "power dressers," 
have greater height, and maintain more distance when 
communicating with individuals considered to be of 
lower social status. 


An interactive process of transmitting information 
between two or more entities. 


Gender influences the manner in which individuals 
communicate. Each culture has gender signals that are 

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recognized as either masculine or feminine and pro- 
vide a basis for distinguishing between members of 
each gender. Examples include differences in posture, 
both standing and sitting, between many men and 
women in the United States. Men usually stand with 
thighs 10 to 15 degrees apart, the pelvis rolled back, 
and the arms slightly away from the body. Women of- 
ten are seen with legs close together, the pelvis tipped 
forward, and the arms close to the body. When sitting, 
men may lean back in the chair with legs apart or may 
rest the ankle of one leg over the knee of the other. 
Women tend to sit more upright in the chair with 
legs together, perhaps crossed at the ankles, or one leg 
crossed over the other at thigh level. 

Roles have traditionally been identified as either 
male or female. For example, in the United States 
masculinity has been traditionally communicated 
through such roles as husband, father, breadwin- 
ner, doctor, lawyer, or engineer. Traditional female 
roles have included wife, mother, homemaker, nurse, 
teacher, or secretary. 

Gender signals are changing in U.S. society as gen- 
der roles become less distinct. Behaviors that had been 
considered typically masculine or feminine in the past 
may now be generally accepted in members of both 
genders. Words such as "unisex" communicate a de- 
sire by some individuals to diminish the distinction 
between the genders and minimize the discrimination 
of either. Roles are changing as both women and men 
enter professions that were once dominated by mem- 
bers of the opposite gender. 

Age or Developmental Level 

Age influences communication, and it is never more 
evident than during adolescence. In their struggle to 
separate from parental confines and establish their 
own identity, adolescents generate a unique pattern 
of communication that changes from generation to 
generation. Words such as "groovy," "cool," "clueless," 
and "awesome" have had special meaning for differ- 
ent generations of adolescents. The technological age 
has produced a whole new language for today's ado- 
lescents. Communication by "text messaging" includes 
such acronyms as BRB (be right back) and MOS (mom 
over shoulder). 

Developmental influences on communication may 
relate to physiological alterations. One example is 
American Sign Language, the system of unique ges- 
tures used by many people who are deaf or hearing im- 
paired. Individuals who are blind at birth never learn 
the subtle nonverbal gesticulations that accompany 

language and that can totally change the meaning of 
the spoken word. 

Environment in Which the Transaction 
Takes Place 

The place where the communication occurs influ- 
ences the outcome of the interaction. Some indi- 
viduals who feel uncomfortable and refuse to speak 
during a group therapy session may be open and 
willing to discuss problems on a one-to-one basis 
with the nurse. 

Territoriality, density, and distance are aspects of en- 
vironment that communicate messages. Territoriality 
is the innate tendency to own space. Individuals lay 
claim to areas around them as their own. This influ- 
ences communication when an interaction takes place 
in the territory "owned" by one or the other. Interper- 
sonal communication can be more successful if the in- 
teraction takes place in a "neutral" area. For example, 
with the concept of territoriality in mind, the nurse 
may choose to conduct the psychosocial assessment in 
an interview room rather than in his or her office or in 
the client's room. 

Density refers to the number of people within 
a given environmental space. It has been shown to 
influence interpersonal interaction. Some studies 
indicate that a correlation exists between prolonged 
high- density situations and certain behaviors, such as 
aggression, stress, criminal activity, hostility toward 
others, and a deterioration of mental and physical 

Distance is the means by which various cultures 
use space to communicate. Hall (1966) identi- 
fied four kinds of spatial interaction, the distances 
that people maintain from each other in their in- 
terpersonal interactions and the kinds of activities 
in which people engage at these various distances. 
Intimate distance is the closest distance that in- 
dividuals will allow between themselves and oth- 
ers. In the United States, this distance, which is 
restricted to interactions of an intimate nature, is 
to 18 inches. Personal distance is approximately 
18 to 40 inches and is reserved for interactions that 
are personal in nature, such as close conversations 
with friends or colleagues. Social distance is about 
4 to 12 feet away from the body. Interactions at this 
distance include conversations with strangers or ac- 
quaintances, such as at a cocktail party or in a pub- 
lic building. A public distance is one that exceeds 
12 feet. Examples include speaking in public or yell- 
ing to someone some distance away. This distance is 

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considered public space, and communicants are free 
to move about in it during the interaction. 

Nonverbal Communication 

It has been estimated that about 70 to 90 percent of 
all effective communication is nonverbal (Oak, 2004). 
Some aspects of nonverbal expression have been dis- 
cussed in the previous section on preexisting conditions 
that influence communication. Other components of 
nonverbal communication include physical appearance 
and dress, body movement and posture, touch, facial 
expressions, eye behavior, and vocal cues or paralan- 
guage. These nonverbal messages vary from culture to 

Physical Appearance and Dress 

Physical appearance and dress are part of the total non- 
verbal stimuli that influence interpersonal responses, 
and, under some conditions, they are the primary de- 
terminants of such responses. Body coverings — both 
dress and hair — are manipulated by the wearer in a 
manner that conveys a distinct message to the receiver. 
Dress can be formal or casual, stylish or sloppy. Hair 
can be long or short, and even the presence or absence 
of hair conveys a message about the person. Other 
body adornments that are also considered potential 
communicative stimuli include tattoos, masks, cos- 
metics, badges, jewelry, and eyeglasses. Some jewelry 
worn in specific ways can give special messages (e.g., a 
gold band or diamond ring worn on the fourth finger 
of the left hand, a boy's class ring worn on a chain 
around a girl's neck, or a pin bearing Greek letters 
worn on the lapel). Some individuals convey a specific 
message with the total absence of any type of body 

Body Movement and Posture 

The way in which an individual positions his or her 
body communicates messages regarding self-esteem, 
gender identity, status, and interpersonal warmth or 
coldness. The individual whose posture is slumped, 
with head and eyes pointed downward, conveys a mes- 
sage of low self-esteem. Specific ways of standing or 
sitting are considered to be either feminine or mascu- 
line within a defined culture. To stand straight and tall 
with head high and hands on hips indicates a superior 
status over the person being addressed. 

Reece and Whitman (1962) identified response be- 
haviors that were used to designate individuals as either 

"warm" or "cold" persons. Individuals who were per- 
ceived as warm responded to others with a shift of pos- 
ture toward the other person, a smile, direct eye contact, 
and hands that remained still. Individuals who responded 
to others with a slumped posture, by looking around the 
room, drumming fingers on the desk, and not smiling 
were perceived as cold. 


Touch is a powerful communication tool. It can elicit 
both negative and positive reactions, depending on the 
people involved and the circumstances of the interac- 
tion. It is a very basic and primitive form of communi- 
cation, and the appropriateness of its use is culturally 

Touch can be categorized according to the message 
communicated (Knapp and Hall, 2001): 

• Functional-professional: This type of touch is 
impersonal and businesslike. It is used to accom- 
plish a task. 


A tailor measuring a customer for a suit or a physician 
examining a client 

• Social-polite: This type of touch is still rather im- 
personal, but it conveys an affirmation or accept- 
ance of the other person. 


A handshake 

• Friendship-warmth: Touch at this level indicates a 
strong liking for the other person — a feeling that he 
or she is a friend. 


Laying one's hand on the shoulder of another 

• Love-intimacy: This type of touch conveys an emo- 
tional attachment or attraction for another person. 


Engaging in a strong, mutual embrace 

• Sexual arousal: Touch at this level is an expression 
of physical attraction only. 

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Table 6-2 

Touching another in the genital region 

Some cultures encourage more touching of vari- 
ous types than others. Individuals in "contact cultures" 
(e.g., France, Latin America, Italy) touch more fre- 
quently than do those in "noncontact cultures" (e.g., 
Germany, United States, Canada) (Givens, 2006). The 
nurse should understand the cultural meaning of touch 
before using this method of communication in specific 

Facial Expressions 

Next to human speech, facial expression is the primary 
source of communication. Facial expressions primarily 
reveal an individual's emotional states, such as happiness, 
sadness, anger, surprise, or fear. The face is a complex 
multimessage system. Facial expressions serve to com- 
plement and qualify other communication behaviors, 
and at times even take the place of verbal messages. A 
summary of feelings associated with various facial ex- 
pressions is presented in Table 6-2. 

Eye Behavior 

Eyes have been called the "windows of the soul." It 
is through eye contact that individuals view and are 
viewed by others in a revealing way. An interpersonal 
connectedness occurs through eye contact. In Ameri- 
can culture, eye contact conveys a personal interest in 
the other person. Eye contact indicates that the com- 
munication channel is open, and it is often the initiat- 
ing factor in verbal interaction between two people. 

Eye behavior is regulated by social rules. These rules 
dictate where, when, for how long, and at whom we can 
look. Staring is often used to register disapproval of the 
behavior of another. People are extremely sensitive to 
being looked at, and if the gazing or staring behavior 
violates social rules, they often assign meaning to it, such 
as, "He kept staring at me, and I began to wonder if I was 
dressed inappropriately or had mustard on my face!" 

Gazing at another's eyes arouses strong emotions. 
Thus, eye contact rarely lasts longer than 3 seconds 
before one or both viewers experience a powerful urge 
to glance away. Breaking eye contact lowers stress lev- 
els (Givens, 2006). 

Vocal Cues or Paralanguage 

Paralanguage, or vocal cues, is the gestural component of 
the spoken word. It consists of pitch, tone, and loudness 

Summary of Facial 

Facial Expression 

Associated Feelings 


Nostril flare 

Anger; arousal 

Wrinkling up 

Dislike; disgust 


Grin; smile 

Happiness; contentment 


Fear; pain 


Anger; frustration 

Canine-type snarl 


Pouted; frown 

Unhappiness; discontented; 





Contempt; disdain 



Anger; unhappiness; 



Surprise; enthusiasm 


Stick out 

Dislike; disagree 



Surprise; excitement 

Narrowed; lids squeezed shut 

Threat; fear 



Stare/blink/look away 

Dislike; disinterest 

Eyes downcast; lack of eye 

Submission; low self-esteem 


Eye contact (generally 

Self-confidence; interest 

intermittent, as opposed 

to a stare) 

Sources: Adapted from Archer (2009); Givens (2006); 
and Hughey (1990). 

of spoken messages; the rate of speaking; expressively 
placed pauses; and emphasis assigned to certain words. 
These vocal cues greatly influence the way individuals 
interpret verbal messages. A normally soft-spoken indi- 
vidual whose pitch and rate of speaking increases may 
be perceived as being anxious or tense. 

Different vocal emphases can alter interpretation of 
the message. For example, consider the following: 

• "I felt SURE you would notice the change." 
Interpretation: I was SURE you would, but you 

• "I felt sure YOU would notice the change." 
Interpretation: I thought YOU would, even if nobody 
else did. 

• "I felt sure you would notice the CHANGE." 
Interpretation: Even if you didn't notice anything 
else, I thought you would notice the CHANGE. 

Verbal cues play a major role in determining re- 
sponses in human communication situations. How a 

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Therapeutic Communication 

Caregiver verbal and nonverbal techniques that fo- 
cus on the care receiver's needs and advance the 
promotion of healing and change. Therapeutic com- 
munication encourages exploration of feelings and 
fosters understanding of behavioral motivation. It 
is nonjudgmental, discourages defensiveness, and 
promotes trust. 

message is verbalized can be as important as what is 

Therapeutic Communication Techniques 

Hays and Larson (1963) identified a number of tech- 
niques to assist the nurse in interacting more therapeu- 
tically with clients. These are the "technical procedures" 
carried out by the nurse working in psychiatry, and they 
should serve to enhance development of a therapeutic 

nurse-client relationship. Table 6-3 includes a list of 
these techniques, a short explanation of their useful- 
ness, and examples of each. 

Nontherapeutic Communication 

Several approaches are considered to be barriers to 
open communication between the nurse and cli- 
ent. Hays and Larson (1963) identified a number of 
these techniques, which are presented in Table 6-4. 
The nurse should recognize and eliminate the use of 
these patterns in his or her relationships with clients. 
Avoiding these communication barriers will maximize 
the effectiveness of communication and enhance the 
nurse- client relationship. 

Process Recordings 

Process recordings are written reports of verbal inter- 
actions with clients. They are verbatim (to the extent 
that this is possible) accounts, written by the nurse or 
student as a tool for improving interpersonal communi- 
cation techniques. The process recording can take many 
forms, but usually includes the verbal and nonverbal 

Table 6-3 

Therapeutic Communication Techniques 




Using Silence 


Giving Recognition 

Offering Self 

Giving Broad Openings 

Offering General Leads 

Placing the Event in Time or Sequence 

Making Observations 

Gives the client the opportunity to collect 
and organize thoughts, to think through 
a point, or to consider introducing a 
topic of greater concern than the one 
being discussed. 

Conveys an attitude of reception and 

Acknowledging; indicating awareness; bet- 
ter than complimenting, which reflects 
the nurse's judgment. 

Making oneself available on an uncondi- 
tional basis, increasing client's feelings of 
self- worth. 

Allows the client to take the initiative in 
introducing the topic; emphasizes the 
importance of the client's role in the 

Offers the client encouragement to 

Clarifies the relationship of events in time 
so that the nurse and client can view 
them in perspective. 

Verbalizing what is observed or perceived. 
This encourages the client to recognize 
specific behaviors and compare percep- 
tions with the nurse. 

"Yes, I understand what you said." 

Eye contact; nodding. 

"Hello, Mr. J. I notice that you made a 

ceramic ash tray in OT" 
"I see you made your bed." 
"I'll stay with you awhile." 
"We can eat our lunch together." 
"I'm interested in you." 
"What would you like to talk about 

"Tell me what you are thinking." 

"Yes, I see." 

"Go on." 

"And after that?" 

"What seemed to lead up to . . .?" 

"Was this before or after . . .?" 

"When did this happen?" 

"You seem tense." 

"I notice you are pacing a lot." 

"You seem uncomfortable when you. . . 


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Table 6- 

Therapeutic Communication Techniques— cont'd 


Encouraging Description of 

Encouraging Comparison 





Seeking Clarification and Validation 

Presenting Reality 

Voicing Doubt 


Asking the client to verbalize what is being 
perceived; often used with clients experi- 
encing hallucinations. 

Asking the client to compare similarities 
and differences in ideas, experiences, or 
interpersonal relationships. This helps 
the client recognize life experiences that 
tend to recur as well as those aspects of 
life that are changeable. 

Repeating the main idea of what the cli- 
ent has said. This lets the client know 
whether or not an expressed statement 
has been understood and gives him or 
her the chance to continue, or to clarify 
if necessary. 

Questions and feelings are referred back to 
the client so that they may be recog- 
nized and accepted, and so that the cli- 
ent may recognize that his or her point 
of view has value — a good technique to 
use when the client asks the nurse for 

Taking notice of a single idea or even a 
single word; works especially well with 
a client who is moving rapidly from one 
thought to another. This technique is 
not therapeutic, however, with the client 
who is very anxious. Focusing should 
not be pursued until the anxiety level has 

Delving further into a subject, idea, 
experience, or relationship; especially 
helpful with clients who tend to remain 
on a superficial level of communica- 
tion. However, if the client chooses 
not to disclose further information, the 
nurse should refrain from pushing or 
probing in an area that obviously creates 

Striving to explain that which is vague or 
incomprehensible and searching for 
mutual understanding; clarifying the 
meaning of what has been said facilitates 
and increases understanding for both 
client and nurse. 

When the client has a misperception of the 
environment, the nurse defines reality 
or indicates his or her perception of the 
situation for the client. 

Expressing uncertainty as to the reality of 
the client's perceptions; often used with 
clients experiencing delusional thinking. 


"Tell me what is happening now." 
"Are you hearing the voices again?" 
"What do the voices seem to be saying?" 
"Was this something like . . .?" 
"How does this compare with the time 

when . . .?" 
"What was your response the last time this 

situation occurred?" 

Client: "I can't study. My mind keeps 

Nurse: "You have trouble concentrating." 
Client: "I can't take that new job. What if I 

can't do it?" 
Nurse: "You're afraid you will fail in this 

new position." 
Client: "What do you think I should do 

about my wife's drinking problem?" 
Nurse: "What do you think you 

should do?" 
Client: "My sister won't help a bit toward 

my mother's care. I have to do it all!" 
Nurse: "You feel angry when she doesn't 

"This point seems worth looking at more 

closely. Perhaps you and I can discuss it 


"Please explain that situation in more 

"Tell me more about that particular 


"I'm not sure that I understand. Would 

you please explain?" 
"Tell me if my understanding agrees with 

"Do I understand correctly that you 

said . . .?" 
"I understand that the voices seem real to 

you, but I do not hear any voices." 
"There is no one else in the room but you 

and me." 
"I understand that you believe that to be 

true, but I find it hard to accept." 
"I find that hard to believe." 
"That seems rather doubtful to me." 

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m Table 6-3 

Therapeutic Communication Techniques— cont'd 


Verbalizing the Implied 

Attempting to Translate Words Into 

Formulating a Plan of Action 


Putting into words what the client has only 
implied or said indirectly; can also be 
used with the client who is mute or is 
otherwise experiencing impaired verbal 
communication. This clarifies that which 
is implicit rather than explicit. 

When feelings are expressed indirectly, 
the nurse tries to "desymbolize" what 
has been said and to find clues to the 
underlying true feelings. 

When a client has a plan in mind for 
dealing with what is considered to be 
a stressful situation, it may serve to 
prevent anger or anxiety from escalating 
to an unmanageable level. 


Client: "It's a waste of time to be here. I 
can't talk to you or anyone." 

Nurse: "Are you feeling that no one under- 

Client: (Mute) 

Nurse: "It must have been very difficult for 
you when your husband died in the fire." 

Client: "I'm way out in the ocean." 

Nurse: "You must be feeling very lonely 
right now." 

"What could you do to let your anger out 

"Next time this comes up, what might you 

do to handle it more appropriately?" 

Source: Adapted from Hays & Larson (1963). 

Table 6-4 

Nontherapeutic Communication Techniques 




Giving Reassurance 


Approving or 

Agreeing or 

Giving Advice 

Indicating to the client that there is no cause for 
anxiety, thereby devaluing the client's feelings; 
may discourage the client from further expres- 
sion of feelings if he or she believes they will 
only be downplayed or ridiculed. 

Refusing to consider or showing contempt for the 
client's ideas or behavior. This may cause the 
client to discontinue interaction with the nurse 
for fear of further rejection. 

Sanctioning or denouncing the client's ideas or 
behavior; implies that the nurse has the right 
to pass judgment on whether the client's ideas 
or behaviors are "good" or "bad" and that the 
client is expected to please the nurse. The 
nurse's acceptance of the client is then seen as 
conditional depending on the client's behavior. 

Indicating accord with or opposition to the 

client's ideas or opinions; implies that the nurse 
has the right to pass judgment on whether 
the client's ideas or opinions are "right" or 
"wrong." Agreement prevents the client from 
later modifying his or her point of view without 
admitting error. Disagreement implies inac- 
curacy, provoking the need for defensiveness on 
the part of the client. 

Telling the client what to do or how to behave 
implies that the nurse knows what is best and 
that the client is incapable of any self-direction. 
It nurtures the client in the dependent role by 
discouraging independent thinking. 

"I wouldn't worry about that if I were you." 

"Everything will be all right." 

Better to say: "We will work on that together." 

"Let's not discuss. . . ." 

"I don't want to hear about. . . ." 

Better to say: "Let's look at that a little closer." 

"That's good. I'm glad that you. . . ." 
"That's bad. I'd rather you wouldn't. . . ." 
Better to say: "Let's talk about how your behavior 
invoked anger in the other clients at dinner." 

"That's right. I agree." 
"That's wrong. I disagree." 
"I don't believe that." 

Better to say: "Let's discuss what you feel is unfair 
about the new community rules." 

"I think you should. . . ." 
"Why don't you. . . ." 

Better to say: "What do you think would be best for 
you to do?" 


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Table 6- 

Nontherapeutic Communication Techniques— cont'd 





Persistent questioning of the client; pushing for 

"Tell me how your mother abused you when you were 

answers to issues the client does not wish to 

a child." 

discuss. This causes the client to feel used and 

"Tell me how you feel toward your mother now that she 

valued only for what is shared with the nurse 

is dead." 

and places the client on the defensive. 

"Now tell me about. . . ." 

Better technique: The nurse should be aware of the 

client's response and discontinue the interaction at the 

first sign of discomfort. 


Attempting to protect someone or something 

"No one here would lie to you." 

from verbal attack. To defend what the client 

"You have a very capable physician. I'm sure he only has 

has criticized is to imply that he or she has no 

your best interests in mind." 

right to express ideas, opinions, or feelings. 

Better to say: "I will try to answer your questions and 

Defending does not change the client's feelings 

clarify some issues regarding your treatment." 

and may cause the client to think the nurse is 

taking sides with those being criticized and 

against the client. 

Requesting an 

Asking the client to provide the reasons for 

"Why do you think that?" 


thoughts, feelings, behavior, and events. Asking 

"Why do you feel this way?" 

"why" a client did something or feels a certain 

"Why did you do that?" 

way can be very intimidating, and implies that the 

Better to say: "Describe what you were feeling just 

client must defend his or her behavior or feelings. 

before that happened." 

Indicating the 

Attributing the source of thoughts, feelings, and 

"What makes you say that?" 

Existence of an 

behavior to others or to outside influences. This 

"What made you do that?" 

External Source of 

encourages the client to project blame for his or 

"What made you so angry last night?" 


her thoughts or behaviors on others rather than 

Better to say: "You became angry when your brother 

accepting the responsibility personally. 

insulted your wife." 

Belittling Feelings 

When the nurse misjudges the degree of the 

Client: "I have nothing to live for. I wish I were dead." 


client's discomfort, a lack of empathy and 

Nurse: "Everybody gets down in the dumps at times. I 

understanding may be conveyed. The nurse 

feel that way myself sometimes." 

may tell the client to "perk up" or "snap out of 

Better to say: "You must be very upset. Tell me what 

it." This causes the client to feel insignificant 

you are feeling right now." 

or unimportant. When one is experiencing 

discomfort, it is no relief to hear that others are 

or have been in similar situations. 

Making Stereotyped 

Cliches and trite expressions are meaningless in 

"I'm fine, and how are you?" 


a nurse-client relationship. When the nurse 

"Hang in there. It's for your own good." 

makes empty conversation, it encourages a like 

"Keep your chin up." 

response from the client. 

Better to say: "The therapy must be difficult for you 
at times. How do you feel about your progress at this 

Using Denial 

Denying that a problem exists blocks discussion 

Client: "I'm nothing." 

with the client and avoids helping the client 

Nurse: "Of course you're something. Everybody is 

identify and explore areas of difficulty. 

Better to say: "You're feeling like no one cares about 
you right now." 


With this technique, the therapist seeks to make 

"What you really mean is. . . ." 

conscious that which is unconscious, to tell the 

"Unconsciously you're saying. . . ." 

client the meaning of his or her experience. 

Better technique: The nurse must leave interpretation 
of the client's behavior to the psychiatrist. The nurse 
has not been prepared to perform this technique, and 
in attempting to do so, may endanger other nursing 
roles with the client. 

Introducing an 

Changing the subject causes the nurse to take 

Client: "I don't have anything to live for." 

Unrelated Topic 

over the direction of the discussion. This may 

Nurse: "Did you have visitors this weekend?" 

occur to get to something that the nurse wants 

Better technique: The nurse must remain open and 

to discuss with the client or to get away from a 

free to hear the client and to take in all that is being 

topic that he or she would prefer not to discuss. 

conveyed, both verbally and nonverbally. 

Source: Adapted from Hays & Larson (1963). 

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communication of both nurse and client. The interac- 
tion provides a means for the nurse to analyze both the 
content and pattern of the interaction. The process re- 
cording is not documentation in and of itself, but should 
be used as a learning tool for professional development. 
An example of one type of process recording is present- 
ed in Table 6-5. 

Active Listening 

To listen actively is to be attentive to what the client is 
saying, both verbally and nonverbally. Attentive listening 
creates a climate in which the client can communicate. 
With active listening the nurse communicates accept- 
ance and respect for the client, and trust is enhanced. A 
climate is established within the relationship that pro- 
motes openness and honest expression. 

Several nonverbal behaviors have been designated 
as facilitative skills for attentive listening. Those listed 
here can be identified by the acronym SOLER: 

S: Sit squarely facing the client. This gives the message 
that the nurse is there to listen and is interested in 
what the client has to say. 

O: Observe an open posture. Posture is considered 
"open" when arms and legs remain uncrossed. This 
suggests that the nurse is "open" to what the client 
has to say. With a "closed" position, the nurse can 
convey a somewhat defensive stance, possibly in- 
voking a similar response in the client. 

L: Lean forward toward the client. This conveys to the 
client that you are involved in the interaction, in- 
terested in what is being said, and making a sincere 
effort to be attentive. 

Table 6- 

Sample Process Recording 

Nurse Verbal 

Client Verbal 

Nurse's Thoughts and 
Feelings Concerning the 


of the Interaction 

Do you still have thoughts 

Not really. I still feel sad, but I 

Felt a little uncomfortable. Al- 

Therapeutic: Asking a direct 

about harming yourself? 

don't want to die. (Looking 

ways a hard question to ask. 

question about suicidal 

(Sitting facing the client; 

at hands in lap.) 


looking directly at client.) 

Tell me what you were feeling 

I was just so angry! To think 

Beginning to feel more 

Therapeutic: Exploring. 

before you took all the pills 

that my husband wants a 

comfortable. Client seems 

Delving further into the 

the other night. (Still using 

divorce now that he has a 

willing to talk and I think 


SOLER techniques of active 

good job. I worked hard to 

she trusts me. 


put him through college. 
(Fists clenched. Face and 
neck reddened.) 

You wanted to hurt him 
because you felt betrayed. 

Seems like a pretty drastic way 
to get your point across. 
(Small frown.) 

How are you feeling about the 
situation now? (SOLER) 

Yes, I can understand that you 
would like things to be the 
way they were before. (Offer 
client a tissue.) 

What do you think are the 
chances of your getting back 
together? (SOLER) 

Yes! If I died, maybe he'd real- 
ize that he loved me more 
than that other woman. 
(Tears starting to well up in 
her eyes.) 

I know. It was a stupid thing to 
do. (Wiping eyes.) 

I don't know. I still love him. I 
want him to come home. I 
don't want him to marry her. 
(Starting to cry again.) 

(Silence. Continues to cry 

None. He's refused marriage 
counseling. He's already 
moved in with her. He says 
it's over. (Wipes tears. Looks 
directly at nurse.) 

Starting to feel sorry for her. 

Trying hard to remain 

Wishing there was an easy 
way to help relieve some 
of her pain. 

I'm starting to feel some anger 
toward her husband. Some- 
times it's so hard to remain 

Relieved to know that she isn't 
using denial about the reality 
of the situation. 

Therapeutic: Attempting to 
translate words into feelings. 

Nontherapeutic: Sounds 
disapproving. Better to have 
pursued her feelings. 

Therapeutic: Focusing on 
her feelings. 

Therapeutic: Conveying 

Therapeutic: Reflecting. 
Seeking client's perception 
of the situation. 


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Table 6- 

Sample Process Recording— cont'd 

Nurse's Thoughts and 

Nurse Verbal 

Client Verbal 

Feelings Concerning the 





of the Interaction 

So how are you preparing to 

I'm going to do the things we 

Positive feeling to know that 

Therapeutic: Formulating a 

deal with this inevitable 

talked about: join a divorced 

she remembers what we 

plan of action. 

outcome? (SOLER) 

women's support group; 

discussed earlier and plans to 

increase my job hours to 

follow through. 

full-time; do some volunteer 

work; and call the suicide 

hotline if I feel like taking 

pills again. (Looks directly 

at nurse. Smiles.) 

It won't be easy. But you have 

Yes, I know I will have hard 

Feeling confident that the ses- 

Therapeutic: Presenting 

come a long way, and I feel 

times. But I also know I have 

sion has gone well; hopeful 


you have gained strength 

support, and I want to go on 

that the client will succeed 

in your ability to cope. 

with my life and be happy 

in what she wants to do with 

(Standing. Looking at client. 

again. (Standing, smiling at 

her life. 



E: Establish eye contact. Direct eye contact is another 
behavior that conveys the nurse's involvement and 
willingness to listen to what the client has to say 
The absence of eye contact, or the constant shifting 
of eye contact, gives the message that the nurse is 
not really interested in what is being said. 

NOTE: Ensure that eye contact conveys warmth 
and is accompanied by smiling and intermittent 
nodding of the head and that it does not come across 
as staring or glaring, which can create intense dis- 
comfort in the client. 

R: Relax. Whether sitting or standing during the in- 
teraction, the nurse should communicate a sense 
of being relaxed and comfortable with the client. 
Restlessness and fidgetiness communicate a lack of 
interest and a feeling of discomfort that are likely to 
be transferred to the client. 


Feedback is a method of communication that helps the 
client consider a modification of behavior. Feedback 
gives information to clients about how they are being 
perceived by others. It should be presented in a manner 
that discourages defensiveness on the part of the client. 
Feedback can be useful to the client if presented with 
objectivity by a trusted individual. 

Some criteria about useful feedback include the 

• Feedback should be descriptive rather than evalu- 
ative and focused on the behavior rather than on 
the client. Avoiding evaluative language reduces the 

need for the client to react defensively. An objective 
description allows the client to take the informa- 
tion and use it in whatever way he or she chooses. 
When the focus is on the client, the nurse makes 
judgments about the client. 


Descriptive and 
focused on 


Focus on client 

"Jane was very upset in group 
today when you called her 'fatty' 
and laughed at her in front of the 

"You were very rude and inconsid- 
erate to Jane in group today." 
"You are a very insensitive person." 

• Feedback should be specific rather than general. 
Information that gives details about the client's be- 
havior can be used more easily than a generalized 
description for modifying the behavior. 



"You just don't pay attention." 
"You were talking to Joe when 
we were deciding on the issue. 
Now you want to argue about 
the outcome." 

• Feedback should be directed toward behavior that the 
client has the capacity to modify. To provide feedback 
about a characteristic or situation that the client 
cannot change will only provoke frustration. 

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Can modify "I noticed that you did not want 

to hold your baby when the 
nurse brought her to you." 

Cannot modify "Your baby daughter is mentally 

retarded because you took drugs 
when you were pregnant." 

• Feedback should impart information rather than 
offer advice. Giving advice fosters dependence and 
may convey the message to the client that he or she 
is not capable of making decisions and solving prob- 
lems independently. It is the client's right and privi- 
lege to be as self-sufficient as possible. 


Imparting "There are various methods of 

information assistance for people who want to 

lose weight, such as Overeaters 
Anonymous, Weight Watchers, 
regular visits to a dietitian, the 
Physician's Weight Loss Pro- 
gram. You can decide what is best 
for you." 
Giving advice "You obviously need to lose a 

great deal of weight. I think the 
Physician's Weight Loss Program 
would be best for you." 

• Feedback should be well timed. Feedback is most 
useful when given at the earliest appropriate oppor- 
tunity following the specific behavior. 


Prompt response 
Delayed response 

"I saw you hit the wall with 
your fist just now when you 
hung up the phone from talk- 
ing to your mother." 
"You need to learn some more 
appropriate ways of dealing 
with your anger. Last week 
after group I saw you pound- 
ing your fist against the wall." 


Nurses who work in the psychiatric/mental health 
field use special skills, or "interpersonal techniques," 
to assist clients in adapting to difficulties or changes 
in life experiences. 

A therapeutic or "helping" relationship is estab- 
lished through use of these interpersonal techniques 
and is based on knowledge of theories of personality 
development and human behavior. 
Therapeutic nurse-client relationships are goal 
oriented. Ideally, the goal is mutually agreed on by 
the nurse and client, and is directed at learning and 
growth promotion. 

The problem-solving model is used in an attempt to 
bring about some type of change in the client's life. 
The instrument of delivery for the process of inter- 
personal nursing is the therapeutic use of self, which 
requires that the nurse possess a strong sense of self- 
awareness and self-understanding. 
Several characteristics that enhance the achievement 
of a therapeutic relationship have been identified. 
They include rapport, trust, respect, genuineness, 
and empathy. 

The tasks associated with the development of a ther- 
apeutic interpersonal relationship have been catego- 
rized into four phases: the preinteraction phase, the 
orientation (introductory) phase, the working phase, 
and the termination phase. 

Interpersonal communication is a transaction be- 
tween the sender and the receiver. 
In all interpersonal transactions, both the sender and 
receiver bring certain preexisting conditions to the 
exchange that influence both the intended message 
and the way in which it is interpreted. Examples of 
these conditions include one's value system, internal- 
ized attitudes and beliefs, culture or religion, social 
status, gender, background knowledge and experi- 
ence, age or developmental level, and the type of en- 
vironment in which the communication takes place. 
Nonverbal expression is a primary communication 
system in which meaning is assigned to various ges- 
tures and patterns of behavior. 
Some components of nonverbal communication in- 
clude physical appearance and dress, body movement 
and posture, touch, facial expressions, eye behavior, and 
vocal cues or paralanguage. The meaning of each of 
these nonverbal components is culturally determined. 
Various techniques of communication that can fa- 
cilitate interaction between nurse and client, as well 
as a number of barriers to effective communication, 
were presented in this chapter. Techniques of ac- 
tive listening and examples of feedback as a method 
of communication for helping the client modify 
behavior also were presented. 

The nurse must be aware of the therapeutic or non- 
therapeutic value of the communication techniques 
used with the client, as they are the "tools" of psy- 
chosocial intervention. 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 

1 . Nurse Mary has been providing care for Tom during his hospital stay. On Tom's day of discharge, 
his wife brings a bouquet of flowers and box of chocolates to his room. He presents these gifts to 
Nurse Mary saying, "Thank you for taking care of me." What is a correct response by the nurse? 

a. "I don't accept gifts from patients." 

b. "Thank you so much! It is so nice to be appreciated." 

c. "Thank you. I will share these with the rest of the staff." 

d. "Hospital policy forbids me to accept gifts from patients." 

2 . Nancy says to the nurse, "I worked as a secretary to put my husband through college, and as soon 
as he graduated, he left me. I hate him! I hate all men!" Which is an empathetic response by the 

a. "You are very angry now. This is a normal response to your loss." 

b. "I know what you mean. Men can be very insensitive." 

c. "I understand completely. My husband divorced me, too." 

d. "You are depressed now, but you will feel better in time." 

3. Which of the following behaviors suggest a possible breach of professional boundaries? Select all 
that apply. 

a. The nurse repeatedly requests to be assigned to a specific client. 

b. The nurse shares the details of her divorce with the client. 

c. The nurse makes arrangements to meet the client outside of the therapeutic environment. 

d. The nurse shares how she dealt with a similar difficult situation. 

4. A client states: "I refuse to shower in this room. I must be very cautious. The FBI has placed a cam 
era in here to monitor my every move." Which of the following is the therapeutic response? 

a. "That's not true." 

b. "I have a hard time believing that is true." 

c. "Surely you don't really believe that." 

d. "I will help you search this room so that you can see there is no camera." 

5. Nancy, a depressed client who has been unkempt and untidy for weeks, today comes to group 
therapy wearing makeup and a clean dress and having washed and combed her hair. Which of the 
following responses by the nurse is most appropriate? 

a. "Nancy, I see you have put on a clean dress and combed your hair." 

b. "Nancy, you look wonderful today!" 

c. "Nancy, I'm sure everyone will appreciate that you have cleaned up for the group today." 

d. "Now that you see how important it is, I hope you will do this every day." 

6. Dorothy was involved in an automobile accident while under the influence of alcohol. She swerved 
her car into a tree and narrowly missed hitting a child on a bicycle. She is in the hospital with 
multiple abrasions and contusions. She is talking about the accident with the nurse. Which of the 
following statements by the nurse is most appropriate? 

a. "Now that you know what can happen when you drink and drive, I'm sure you won't let it hap- 
pen again." 

b. "You know that was a terrible thing you did. That child could have been killed." 

c. "I'm sure everything is going to be okay now that you understand the possible consequences of 
such behavior." 

d. "How are you feeling about what happened?" 



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7. Judy has been in the hospital for 3 weeks. She has used Valium "to settle my nerves" for the past 
1 5 years. She was admitted by her psychiatrist for safe withdrawal from the drug. She has passed 
the physical symptoms of withdrawal at this time, but states to the nurse, "I don't know if I will 
make it without Valium after I go home. I'm already starting to feel nervous. I have so many 
personal problems." Which is the most appropriate response by the nurse? 

a. "Why do you think you have to have drugs to deal with your problems?" 

b. "Everybody has problems, but not everybody uses drugs to deal with them. You'll just have to 
do the best that you can." 

c. "We will just have to think about some things that you can do to decrease your anxiety without 
resorting to drugs." 

d. "Just hang in there. I'm sure everything is going to be okay." 

8. Mrs. S. asks the nurse, "Do you think I should tell my husband about my affair with my boss?" 
Which is the most appropriate response by the nurse? 

a. "What do you think would be best for you to do?" 

b. "Of course you should. Marriage has to be based on truth." 

c. "Of course not. That would only make things worse." 

d. "I can't tell you what to do. You have to decide for yourself." 

9. Carol, an adolescent, just returned from group therapy and is crying. She says to the nurse, "All 
the other kids laughed at me! I try to fit in, but I always seem to say the wrong thing. I've never 
had a close friend. I guess I never will." Which is the most appropriate response by the nurse? 

a. "What makes you think you will never have any friends?" 

b. "You're feeling pretty down on yourself right now." 

c. "I'm sure they didn't mean to hurt your feelings." 

d. "Why do you feel this way about yourself?" 

10. Which of the following tasks are associated with the orientation phase of relationship 
development? Select all that apply. 

a. Promoting the client's insight and perception of reality. 

b. Creating an environment for the establishment of trust and rapport. 

c. Using the problem-solving model toward goal fulfillment. 

d. Obtaining available information about the client from various sources. 

e. Formulating nursing diagnoses and setting goals. 


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March 5, 2009 from 

College and Association of Registered Nurses of Alberta (CARNA). 
(2005). Professional boundaries for registered nurses: Guidelines for the 
nurse-client relationship. Edmonton, Alberta, Canada: CARNA. 

Givens, D.B. (2006). The nonverbal dictionary. Center for Nonverbal 
Studies. Retrieved March 1, 2009 from 
web/2 0060624062 422/ 

Hilz, L.M. (2008). Transference and countertransference. Kathis 
Mental Health Review. Retrieved February 28, 2009 from 
-transference- 3 .htm 

Hughey, J.D. (1990). Speech communication. Stillwater: Oklahoma 
State University. 

Knapp, M.L., & Hall, JA. (2001). Nonverbal communication in 
human interaction (5th ed.). Belmont, CA: Wadsworth. 

Oak, C. (2004, November 8). Enhancing communication skills. 
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Peplau, H.E. (1991). Interpersonal relations in nursing. New York: 

Peternelj -Taylor, C.A., & Yonge, O. (2003). Exploring boundaries 
in the nurse-client relationship: Professional roles and responsi- 
bilities. Perspectives in Psychiatric Care, 39(2), 55-66. 

Raskin, N.J., Rogers, CR., &Witty, M.C. (201 1). Client-centered 
therapy. In R.J. Corsini & D. Wedding (Eds), Current psychothera- 
pies (9th ed.). Belmont, CA Brooks/Cole. 

Registered Nurses' Association of British Columbia (RNABC). 
(2003). Nurse-Client Relationships. Vancouver, British Columbia, 
Canada: RNABC. 

Sadock, B.J., & Sadock, VA. (2007). Synopsis of psychiatry: Behavioral 
sciences/clinical psychiatry (10th ed.). Philadelphia: Lippincott 
Williams & Wilkins. 

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Coltrane, E, & Pugh, C. (1978). Danger signals in staff/patient Reece, M., & Whitman, R. (1962). Expressive movements, warmth, 

relationships. Journal of Psychiatric Nursing & Mental Health and verbal reinforcement. Journal of Abnormal and Social Psychol- 

Services, 16(6), 34-36. ' " ogy, 64, 234-236. 

Hall, E.T. (1966). The hidden dimension. Garden City, NY: Sullivan, H.S. (1953). The interpersonal theory of psychiatry. 

Doubleday. New York: WW Norton. 

Hays, J.S., & Larson, K.H. (1963). Interacting with patients. Travelbee, J. (1971). Interpersonal aspects of nursing (2nd ed.). 

New York: Macmillan. Philadelphia: EA. Davis. 
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2338_Ch06_105-128.indd 128 8/31/10 5:57:23 PM 


H A P T E R 

The Nursing Process 

in Psychiatric/Mental 

Health Nursing 















case management 

case manager 

concept mapping 

critical pathways of care 

Focus Charting® 


managed care 

Nursing Interventions 
Classification (NIC) 

Nursing Outcomes 
Classification (NOC) 

nursing process 

PIE charting 

recording (POR) 


nursing diagnosis 


After reading this chapter, the student will be able to: 

1. Define nursing process. 

2. Identify six steps of the nursing process 
and describe nursing actions associated 
with each. 

3. Describe the benefits of using nursing 

4. Discuss the list of nursing diagnoses ap- 
proved by NANDA International for clini- 
cal use and testing. 

5. Define and discuss the use of case man- 
agement and critical pathways of care in 
the clinical setting. 

6. Apply the six steps of the nursing process 
in the care of a client within the psychiat- 
ric setting. 

7. Document client care that validates use of 
the nursing process. 


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Please read the chapter and answer the following questions. 

1. Nursing outcomes (sometimes referred 
to as goals) are derived from the nursing 
diagnosis. Name two essential aspects of 
an acceptable outcome or goal. 

2. Define managed care. 

3. The American Nurses Association (ANA) 
identifies certain interventions that may 

only be performed by psychiatric nurses 
in advanced practice. What are they? 
In Focus Charting®, one item cannot be 
used as the focus for documentation. 
What is this item? 


For many years, the nursing process has provided a 
systematic framework for the delivery of nursing care. 
It is nursing's means of fulfilling the requirement for a 
scientific methodology required in order to be considered 
a profession. 

This chapter examines the steps of the nursing proc- 
ess as they are set forth by the American Nurses Asso- 
ciation (ANA) in Nursing: Scope and Standards of Practice 
(ANA, 2004). An explanation is provided for the im- 
plementation of case management and the tool used 
in the delivery of care with this methodology, critical 
pathways of care. A description of concept mapping is 
included, and documentation that validates the use of 
the nursing process is discussed. 

are expected to follow as they provide care for their 
clients. The ANA (2004) states: 

The six Standards of Practice describe a component 
level of nursing care as demonstrated by the critical 
thinking model known as the nursing process. The 
nursing process includes the components of assess- 
ment, diagnosis, outcomes identification, planning, 
implementation, and evaluation. The nursing process 
encompasses all significant actions taken by regis- 
tered nurses, and forms the foundation of the nurse's 
decision-making, (p. 4) 

Following are the standards of practice for psychi- 
atric/mental health nurses as set forth by the ANA, 
APNA, and ISPN (2007). 



The nursing process consists of six steps and uses a 
problem-solving approach that has come to be ac- 
cepted as nursing's scientific methodology. It is goal 
directed, with the objective being delivery of quality 
client care. 

Nursing process is dynamic, not static. It is an ongo- 
ing process that continues for as long as the nurse and 
client have interactions directed toward change in the 
client's physical or behavioral responses. Figure 7-1 
presents a schematic of the ongoing nursing process. 

Standards of Practice 

The ANA, in collaboration with the American Psychi- 
atric Nurses Association (APNA) and the International 
Society of Psychiatric-Mental Health Nurses (ISPN), 
has delineated a set of standards that psychiatric nurses 






Outcome identification 


FIGURE 7-1 The ongoing nursing process. 

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A systematic, dynamic process by which the nurse, 
through interaction with the client, significant oth- 
ers, and health-care providers, collects and analyzes 
data about the client. Data may include the following 
dimensions: physical, psychological, sociocultural, 
spiritual, cognitive, functional abilities, developmen- 
tal, economic, and lifestyle (ANA, 2004). 

Nursing Diagnosis 

Clinical judgments about individual, family, or 
community responses to actual or potential health 
problems/life processes. A nursing diagnosis pro- 
vides the basis for selection of nursing interven- 
tions to achieve outcomes for which the nurse is 
accountable (NANDA International, 2009a). 

Standard 1. Assessment 

The psychiatric/mental health registered nurse collects com- 
prehensive health data that is pertinent to the patient's 
health or situation. 

In this first step, information is gathered from which 
to establish a database for determining the best pos- 
sible care for the client. Information for this database 
is gathered from a variety of sources including inter- 
views with the client or family, observation of the client 
and his or her environment, consultation with other 
health-team members, review of the client's records, 
and a nursing physical examination. A biopsychosocial 

assessment tool based on the stress-adaptation frame- 
work is included in Box 7-1. 

An example of a simple and quick mental status 
evaluation is presented in Table 7-1. Its focus is on 
the cognitive aspects of mental functioning. Areas 
such as mood, affect, thought content, judgment, and 
insight are not evaluated. A number of these types of 
tests are available, but they must be considered only 
a part of the comprehensive diagnostic assessment. 
A mental status assessment guide, with explanations 
and selected sample interview questions, is provided 
in Appendix D. 

Box 7-1 Nursing History and Assessment Tool 

I. General Information 
Client name: 

Room number: 



Sex: Name and phone no. of significant other 


Allergies :_ 


Vital signs: TPR/BP_ 

Dominant language:. 
Marital status: 

. City of residence:. 

. Diagnosis (admitting & current):. 

Chief complaint:_ 

Conditions of admission: 


Accompanied by:. 

Route of admission (wheelchair; ambulatory; cart):. 
Admitted from: 


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Box 7-1 Nursing History and Assessment Tool— cont'd 

II. Predisposing Factors 
A. Genetic Influences 

1. Family configuration (use genograms): 

Family of origin: Present family: 

Family dynamics (describe significant relationships between family members) :_ 

2. Medical/psychiatric history: 
a. Client: 

b. Family members :_ 

3 . Other genetic influences affecting present adaptation. This might include effects specific to gender, race, appear- 
ance, such as genetic physical defects, or any other factor related to genetics that is affecting the client's adaptation 
that has not been mentioned elsewhere in this assessment. 

B. Past Experiences 

1 . Cultural and social history: 

a. Environmental factors (family living arrangements, type of neighborhood, special working conditions): 

b. Health beliefs and practices (personal responsibility for health; special self-care practices): 

c. Religious beliefs and practices: . 

d. Educational background:. 

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Box 7-1 Nursing History and Assessment Tool— cont'd 

e. Significant losses/changes (include dates):. 

f. Peer/friendship relationships:. 

g. Occupational history:. 

h. Previous pattern of coping with stress :_ 

i. Other lifestyle factors contributing to present adaptations 

C. Existing Conditions 

1. Stage of development (Erikson): 

a. Theoretically: 

b. Behaviorally: 

c. Rationale: 

2. Support systems:. 

3 . Economic security:. 

4. Avenues of productivity/contribution: 
a. Current job status: 

b. Role contributions and responsibility for others:. 

III. Precipitating Event 

Describe the situation or events that precipitated this illness/hospitalization:. 


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Box 7-1 Nursing History and Assessment Tool— cont'd 

IV Client's Perception of the Stressor 

Client's or family member's understanding or description of stressor/illness and expectations of hospitalization: 

V Adaptation Responses 
A. Psychosocial 

1. Anxiety level (circle level, and check the behaviors that apply): mild moderate severe panic 

calm friendly_ 

. passive. 


impaired attention 


disoriented fearful 

. alert perceives environment correctly_ 

"jittery" unable to concentrate 

rapid speech withdrawn confused 

. hyperventilating_ 

. misinterpreting the environment (hallu- 
cinations or delusions) depersonalization obsessions compulsions 

somatic complaints excessive hyperactivity other 

2. Mood/affect (circle as many as apply): happiness sadness dejection despair elation euphoria 
suspiciousness apathy (little emotional tone) anger/hostility 

3. Ego defense mechanisms (describe how used by client): 










Reaction formation:. 



4. Level of self-esteem (circle one): low moderate high 
Things client likes about self: 

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Box 7-1 Nursing History and Assessment Tool— cont'd 

Things client would like to change about self:_ 

Objective assessment of self-esteem: 
Eye contact: 

General appearance:. 

Personal hygiene:. 

Participation in group activities and interactions with others :_ 

5. Stage and manifestations of grief (circle one): 

denial anger bargaining depression acceptance 

Describe the client's behaviors that are associated with this stage of grieving in response to 

loss or change: 

6. Thought processes (circle as many as apply): clear logical easy to follow relevant confused 
blocking delusional rapid flow of thoughts slowness in thought association suspicious 
Recent memory: loss intact Remote memory: loss intact 


7. Communication patterns (circle as many as apply): clear coherent slurred speech incoherent neologisms 
loose associations flight of ideas aphasic perseveration rumination tangential speech loquaciousness 
slow, impoverished speech speech impediment (describe): 


8. Interaction patterns (describe client's pattern of interpersonal interactions with staff and peers on the unit, e.g., 
manipulative, withdrawn, isolated, verbally or physically hostile, argumentative, passive, assertive, aggressive, 
passive-aggressive, other): 

Reality orientation (check those that apply): 

Oriented to: time person_ 

place situation 


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Box 7-1 Nursing History and Assessment Tool— cont'd 

10. Ideas of destruction to self/others? Yes No 
If yes, consider plan; available means: 

B. Physiological 

1. Psychosomatic manifestations (describe any somatic complaints that may be stress-related) :_ 

2. Drug history and assessment: 
Use of prescribed drugs: 



Use of over-the-counter drugs: 



Use of street drugs or alcohol: 




3. Pertinent physical assessments: 

a. Respirations: normal labored_ 

Rate: Rhythm: 

b. Skin: warm_ 


. moist_ 



. pink_ 

poor turgor_ 


Evidence of: rash 

loss of hair other_ 


needle tracts 


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Box 7-1 Nursing History and Assessment Tool— cont'd 

c. Musculoskeletal status: weakness tremors_ 

Degree of range of motion (describe limitations):. 

Pain (describe) :_ 

Skeletal deformities (describe):. 

Coordination (describe limitations): 

d. Neurological status: 

History of (check all that apply): seizures (describe method of control):. 

headaches (describe location and frequency):. 

fainting spells dizziness 

tingling/numbness (describe location): 

e. Cardiovascular: B/P: Pulse: 

History of (check all that apply): 

hypertension palpitations 

heart murmur chest pain 

shortness of breath pain in legs 

phlebitis ankle/leg edema 

numbness/tingling in extremities 

varicose veins 

f. Gastrointestinal: 

Usual diet pattern: 

Food allergies: 

Dentures? Upper Lower 

Any problems with chewing or swallowing? _ 

Any recent change in weight? _ 
Any problems with: 


Relieved by: 

Relieved by: 

History of ulcers? 

Usual bowel pattern: 

Constipation? Diarrhea? 

Type of self-care assistance provided for either of the above problems:. 


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Box 7-1 Nursing History and Assessment Tool— cont'd 

Genitourinary/Reproductive : 

Usual voiding pattern: 

Urinary hesitancy? 


. Frequency? 

. Pain/burning?_ 


Any genital lesions ?_ 


History of sexually transmitted disease?_ 
If yes, please explain: 

Any concerns about sexuality/sexual activity?. 

Method of birth control used:. 


Date of last menstrual cycle:_ 

Length of cycle: 

Problems associated with menstruation? 

Breasts: Pain/tenderness?_ 


Lumps ? 

. Discharge?_ 
. Dimpling?_ 

Practice breast self-examination?_ 


Penile discharge?_ 

Prostate problems?_ 
h. Eyes: YES 







Double vision? 



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Box 7-1 Nursing History and Assessment Tool— cont'd 


i. Ears: 



Difficulty hearing? 

Hearing aid? 


j. Medication side effects: 

What symptoms is the client experiencing that may be attributed to current medication usage? 

k. Altered lab values and possible significance: . 

1. Activity/rest patterns: 

Exercise (amount, type, frequency):. 

Leisure time activities: 

Patterns of sleep: Number of hours per night:_ 
Use of sleep aids? 

Pattern of awakening during the night? 

Feel rested upon awakening? . 

m. Personal hygiene/activities of daily living: 

Patterns of self-care: independent 

Requires assistance with: mobility 





Statement describing personal hygiene and general appearance:. 

n. Other pertinent physical assessments:_ 


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Box 7-1 Nursing History and Assessment Tool— cont'd 

VI. Summary of Initial Psychosocial/Physical Assessment: 
Knowledge Deficits Identified: 

Nursing Diagnoses Indicated: 

Standard 2. Diagnosis 

The psychiatric/mental health registered nurse analyzes the 
assessment data to determine diagnoses or problems, includ- 
ing level of risk. 

In the second step, data gathered during the assess- 
ment are analyzed. Diagnoses and potential problem 
statements are formulated and prioritized. Diagnoses 
conform to accepted classification systems, such as the 
NANDA International Nursing Diagnosis Classifica- 
tion (see Appendix B); International Classification of 

Diseases (World Health Organization [WHO], 1993); 
and Diagnosis and Statistical Manual of Mental Disorders, 
Fourth Edition, Text revision (DSM-IV-TR) (APA, 2000) 
(see Appendix A). 

Standard 3. Outcomes Identification 

The psychiatric/mental health registered nurse identifies ex- 
pected outcomes for a plan individualized to the patient or 
to the situation. 

Table 7-1 

Brief Mental Status Evaluation 

Area of Mental Function 

Evaluation Activity 

Orientation to time 
Orientation to place 
Attention and immediate recall 

Abstract thinking 
Recent memory 
Naming objects 

Ability to follow simple verbal command 
Ability to follow simple written command 

Ability to use language correctly 

Ability to concentrate 

Understanding spatial relationships 

"What year is it? What month is it? What day is it?" (3 points) 

"Where are you now?" (1 point) 

"Repeat these words now: bell, book, & candle." (3 points) 

"Remember these words and I will ask you to repeat them in a few minutes." 

"What does this mean: No use crying over spilled milk." (3 points) 

"Say the three words I asked you to remember earlier." (3 points) 

Point to eyeglasses and ask, "What is this?" Repeat with one other item (e.g., calendar, 

watch, pencil). (2 points possible) 
"Tear this piece of paper in half and put it in the trash container." (2 points) 
Write a command on a piece of paper (e.g., TOUCH YOUR NOSE), give the paper to 

the patient and say, "Do what it says on this paper. (1 point for correct action) 
Ask the patient to write a sentence. (3 points if sentence has a subject, a verb, and has valid 

"Say the months of the year in reverse, starting with December." (1 point each for correct 

answers from November through August; 4 points possible) 
Draw a clock; put in all the numbers; and set the hands on 3 o'clock, (clock circle = 

1 point; numbers in correct sequence = 1 point; numbers placed on clock correctly = 

1 point; two hands on the clock = 1 point; hands set at correct time = 1 point; 5 points 


Scoring: 30-21 = normal; 20-1 1 = mild cognitive impairment; 10-0 = severe cognitive impairment (scores are not absolute and 

must be considered within the comprehensive diagnostic assessment). 
Sources: The Merck Manual of Health & Aging (2005); Folstein, Folstein, & McHugh (1975); Kaufman & Zun (1995); 

Kokman et al (1991); and Pfeiffer (1975). 

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Measurable, expected, patient-focused goals that 
translate into observable behaviors (ANA, 2004). 

Expected outcomes are derived from the diagnosis. 
They must be measurable and include a time estimate 
for attainment. They must be realistic for the client's 
capabilities and are most effective when formulated 
cooperatively by the interdisciplinary team members, 
the client, and significant others. 

Nursing Outcomes Classification (NOC) 

The Nursing Outcomes Classification (NOC) is a 

comprehensive, standardized classification of patient/ 
client outcomes developed to evaluate the effects of 
nursing interventions (Johnson, Maas, & Moorhead, 
2004). The outcomes have been linked to NANDA 
diagnoses and to the Nursing Interventions Classi- 
fication (NIC). NANDA, NIC, and NOC represent 
all domains of nursing and can be used together or 
separately (Johnson et al, 2006). 

Each NOC outcome has a label name, a definition, a 
list of indicators to evaluate client status in relation to 
the outcome, and a five-point Likert scale to measure 
client status (Johnson et al, 2006). The 330 NOC out- 
comes include 311 individual, 10 family, and 9 com- 
munity level outcomes. 

Standard 4. Planning 

The psychiatric/mental health registered nurse develops a 
plan that prescribes strategies and alternatives to attain ex- 
pected outcomes. 

The care plan is individualized to the client's mental 
health problems, condition, or needs and is developed 
in collaboration with the client, significant others, and 
interdisciplinary team members, if possible. For each 
diagnosis identified, the most appropriate interven- 
tions, based on current psychiatric/mental health nurs- 
ing practice and research, are selected. Client educa- 
tion and necessary referrals are included. Priorities for 
delivery of nursing care are determined. 

Nursing Interventions Classification (NIC) 

NIC is a comprehensive, standardized language de- 
scribing treatments that nurses perform in all settings 
and in all specialties. NIC includes both physiological 

and psychosocial interventions, as well as those for ill- 
ness treatment, illness prevention, and health promo- 
tion. NIC interventions are comprehensive, based 
on research, and reflect current clinical practice. 
They were developed inductively based on existing 

NIC contains 514 interventions, each with a defi- 
nition and a detailed set of activities that describe 
what a nurse does to implement the intervention. 
The use of a standardized language is thought to 
enhance continuity of care and facilitate communi- 
cation among nurses and between nurses and other 

Standard 5. Implementation 

The psychiatric/mental health registered nurse implements 
the identified plan. 

Interventions selected during the planning stage 
are executed, taking into consideration the nurse's 
level of practice, education, and certification. The 
care plan serves as a blueprint for delivery of safe, 
ethical, and appropriate interventions. Documenta- 
tion of interventions also occurs at this step in the 
nursing process. 

Several specific interventions are included among 
the standards of psychiatric/mental health clinical 
nursing practice (ANA, APNA, & ISPN, 2007): 

Standard 5 A. Coordination of Care 

The psychiatric/mental health registered nurse coor- 
dinates care delivery. 

Standard 5B. Health Teaching and Health 

The psychiatric/mental health registered nurse employs 
strategies to promote health and a safe environment. 

Standard 5C. Milieu Therapy 

The psychiatric/mental health registered nurse pro- 
vides, structures, and maintains a safe and therapeutic 
environment in collaboration with patients, families, 
and other health-care clinicians. 

Standard 5D. Pharmacological, Biological, 
and Integrative Therapies 

The psychiatric/mental health registered nurse in- 
corporates knowledge of pharmacological, biological, 
and complementary interventions with applied clinical 
skills to restore the patient's health and prevent further 

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Standard 5E. Prescriptive Authority and 

The psychiatric/mental health advanced practice reg- 
istered nurse uses prescriptive authority, procedures, 
referrals, treatments, and therapies in accordance with 
state and federal laws and regulations. 

Standard 5F. Psychotherapy 

The psychiatric/mental health advanced practice reg- 
istered nurse conducts individual, couples, group, and 
family psychotherapy using evidence-based psycho- 
therapeutic frameworks and nurse-patient therapeutic 

Standard 5G. Consultation 

The psychiatric/mental health advanced practice reg- 
istered nurse provides consultation to influence the 
identified plan, enhance the abilities of other clinicians 
to provide services for patients, and effect change. 

Standard 6. Evaluation 

The psychiatric/mental health registered nurse evalu- 
ates progress toward attainment of expected outcomes. 
During the evaluation step, the nurse measures the 
success of the interventions in meeting the outcome 
criteria. The client's response to treatment is docu- 
mented, validating use of the nursing process in the 
delivery of care. The diagnoses, outcomes, and plan of 
care are reviewed and revised as need is determined by 
the evaluation. 


The concept of nursing diagnosis is not new. For cen- 
turies, nurses have identified specific client responses 
for which nursing interventions were used in an effort 
to improve quality of life. Historically, however, the 
autonomy of practice to which nurses were entitled by 



The process of determining both the client's 
progress toward the attainment of expected out- 
comes and the effectiveness of nursing care. 

virtue of their licensure was lacking in the provision 
of nursing care. Nurses assisted physicians as required 
and performed a group of specific tasks that were con- 
sidered within their scope of responsibility. 

The term diagnosis in relation to nursing first be- 
gan to appear in the literature in the early 1950s. The 
formalized organization of the concept, however, was 
initiated only in 1973, with the convening of the First 
Task Force to Name and Classify Nursing Diagnoses. 
The Task Force of the National Conference Group 
on the Classification of Nursing Diagnoses was devel- 
oped during this conference (NANDA International, 
2009b). These individuals were charged with the task 
of identifying and classifying nursing diagnoses. 

Also in the 1970s, the ANA began to write standards 
of practice around the steps of the nursing process, 
of which nursing diagnosis is an inherent part. This 
format encompassed both the general and specialty 
standards outlined by the ANA. The standards of 
psychiatric/mental health nursing practice are sum- 
marized in Box 7-2. 

From this progression a statement of policy was 
published in 1980 and included a definition of nursing. 
The ANA defined nursing as "the diagnosis and treat- 
ment of human responses to actual or potential health 
problems" (ANA, 2003). This definition has been ex- 
panded to describe more appropriately nursing's com- 
mitment to society and to the profession itself. The 
ANA (2003) defines nursing as follows: 

Nursing is the protection, promotion, and optimiza- 
tion of health and abilities, prevention of illness and 
injury, alleviation of suffering through the diagnosis 
and treatment of human response, and advocacy in 
the care of individuals, families, communities, and 
populations, (p. 6) 

Nursing diagnosis is an inherent component of both 
the original and expanded definitions. 

Decisions regarding professional negligence are made 
based on the standards of practice defined by the ANA 
and the individual state nursing practice acts. A number 
of states have incorporated the steps of the nursing 
process, including nursing diagnosis, into the scope of 
nursing practice described in their nursing practice acts. 
When this is the case, it is the legal duty of the nurse to 
show that nursing process and nursing diagnosis were 
accurately implemented in the delivery of nursing care. 

NANDA International evolved from the original 
task force that was convened in 1973 to name and 
classify nursing diagnoses. The major purpose of 
NANDA International is "to develop, refine and 
promote terminology that accurately reflects nurses' 

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Box 7-2 Standards of Psychiatric/Mental Health Clinical Nursing Practice 

Standard 1. Assessment 

The psychiatric/mental health registered nurse collects 
comprehensive health data that is pertinent to the pa- 
tient's health or situation. 

Standard 2. Diagnosis 

The psychiatric/mental health registered nurse analyzes 
the assessment data to determine diagnoses or problems, 
including level of risk. 

Standard 3. Outcomes Identification 

The psychiatric/mental health registered nurse identifies 
expected outcomes for a plan individualized to the patient 
or to the situation. 

Standard 4. Planning 

The psychiatric/mental health registered nurse develops 
a plan that prescribes strategies and alternatives to attain 
expected outcomes. 

Standard 5. Implementation 

The psychiatric/mental health registered nurse imple- 
ments the identified plan. 

Standard 5A. Coordination of Care 

The psychiatric/mental health registered nurse coordi- 
nates care delivery. 

Standard 5B. Health Teaching and Health 

The psychiatric/mental health registered nurse employs 
strategies to promote health and a safe environment. 

Standard 5C. Milieu Therapy 

The psychiatric/mental health registered nurse provides, 
structures, and maintains a safe and therapeutic environment 

in collaboration with patients, families, and other health- 
care clinicians. 

Standard 5D. Pharmacological, Biological, and 
Integrative Therapies 

The psychiatric/mental health registered nurse incorpo- 
rates knowledge of pharmacological, biological, and com- 
plementary interventions with applied clinical skills to re- 
store the patient's health and prevent farther disability. 

Standard 5E. Prescriptive Authority and Treatment 

The psychiatric/mental health advanced practice registered 
nurse uses prescriptive authority, procedures, referrals, 
treatments, and therapies in accordance with state and 
federal laws and regulations. 

Standard 5F Psychotherapy 

The psychiatric/mental health advanced practice registered 
nurse conducts individual, couples, group, and family 
psychotherapy using evidence-based psychotherapeutic 
frameworks and nurse-patient therapeutic relationships. 

Standard 5G. Consultation 

The psychiatric/mental health advanced practice registered 
nurse provides consultation to influence the identified 
plan, enhance the abilities of other clinicians to provide 
services for patients, and effect change. 

Standard 6. Evaluation 

The psychiatric/mental health registered nurse evaluates 
progress toward attainment of expected outcomes. 

Source: ANA, APNA,( 

: ISPN. (2007). Psychiatric-mental health nursing: Scope and standards of Practice. Silver Spring, MD: ANA. With per- 

clinical judgments. This unique, evidence-based perspec- 
tive includes social, psychological and spiritual dimen- 
sions of care" (NANDA International, 2009c). A list of 
nursing diagnoses approved by NANDA International 
for use and testing is presented in Appendix B. This list 
is by no means exhaustive or all-inclusive. For purposes 
of this text, however, the existing list will be used in an 
effort to maintain a common language within nursing 
and to encourage clinical testing of what is available. 

The use of nursing diagnosis affords a degree of au- 
tonomy that historically has been lacking in the prac- 
tice of nursing. Nursing diagnosis describes the client's 
condition, facilitating the prescription of interventions 
and establishment of parameters for outcome criteria 
based on what is uniquely nursing. The ultimate bene- 
fit is to the client, who receives effective and consistent 

nursing care based on knowledge of the problems that 
he or she is experiencing and of the most beneficial 
nursing interventions to resolve them. 


The concept of case management evolved with the 
advent of diagnosis-related groups (DRGs) and short- 
er hospital stays. Case management is an innovative 
model of care delivery than can result in improved 
client care. Within this model, clients are assigned a 
manager who negotiates with multiple providers to 
obtain diverse services. This type of health-care deliv- 
ery process serves to decrease fragmentation of care 
while striving to contain cost of services. 

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Case management in the acute care setting strives to 
organize client care through an episode of illness so that 
specific clinical and financial outcomes are achieved 
within an allotted time frame. Commonly, the allotted 
time frame is determined by the established protocols 
for length of stay as defined by the DRGs. 

Case management has been shown to be an ef- 
fective method of treatment for individuals with a 
chronic mental illness. This type of care strives to 
improve functioning by assisting the individual to 
solve problems, improve work and socialization 
skills, promote leisure-time activities, and enhance 
overall independence. 

Ideally, case management incorporates concepts 
of care at the primary, secondary, and tertiary levels 
of prevention. Various definitions have emerged and 
should be clarified, as follows. 

Managed care refers to a strategy employed by pur- 
chasers of health services who make determinations 
about various types of services in order to maintain 
quality and control costs. In a managed care program, 
individuals receive health care based on need, as as- 
sessed by coordinators of the providership. Managed 
care exists in many settings, including (but not limited 
to) the following: 

• Insurance-based programs 

• Employer-based medical providerships 

• Social service programs 

• The public health sector 

Managed care may exist in virtually any setting in 
which medical providership is a part of the service, that 
is, in any setting in which an organization (whether pri- 
vate or government based) is responsible for payment 
of health-care services for a group of people. Examples 
of managed care are health maintenance organizations 
(HMOs) and preferred provider organizations (PPOs). 

Case management is the method used to achieve 
managed care. It is the actual coordination of services 
required to meet the needs of a client within the frag- 
mented health-care system. Case management strives 
to help at-risk clients prevent avoidable episodes of ill- 
ness. Its goal is to provide these services while attempt- 
ing to control health-care costs to the consumer and 
third-party payers. 

Types of clients who benefit from case management 
include (but are not limited to) the following: 

• The frail elderly 

• The developmentally disabled 

• The physically handicapped 

• The mentally handicapped 

• Individuals with long-term medically complex prob- 
lems that require multifaceted, costly care (e.g., high- 
risk infants, those with HIV or AIDS, and transplant 

• Individuals who are severely compromised by an 
acute episode of illness or an acute exacerbation of a 
chronic illness (e.g., schizophrenia) 

The case manager is responsible for negotiating 
with multiple health-care providers to obtain a vari- 
ety of services for the client. Nurses are exceptionally 
qualified to serve as case managers. The very nature of 
nursing, which incorporates knowledge about the bio- 
logical, psychological, and sociocultural aspects related 
to human functioning, makes nurses highly appropriate 
as case managers. Several years of experience as a reg- 
istered nurse is usually required for employment as a 
case manager. Some case management programs prefer 
master's-prepared clinical nurse specialists who have 
experience working with the specific populations for 
whom the case management service will be rendered. 

Critical Pathways of Care 

Critical pathways of care (CPCs) have emerged as 
the tools for provision of care in a case management 
system. A critical pathway is a type of abbreviated 
plan of care that provides outcome-based guidelines 
for goal achievement within a designated length of 
stay. A sample CPC is presented in Table 7-2. Only 
one nursing diagnosis is used in this sample. A CPC 
may have nursing diagnoses for several individual 

CPCs are intended to be used by the entire interdis- 
ciplinary team, which may include a nurse case manager, 
clinical nurse specialist, social worker, psychiatrist, psy- 
chologist, dietitian, occupational therapist, recreational 
therapist, chaplain, and others. The team decides what 
categories of care are to be performed, by what date, and 
by whom. Each member of the team is then expected to 
carry out his or her functions according to the time line 
designated on the CPC. The nurse, as case manager, is 
ultimately responsible for ensuring that each of the as- 
signments is carried out. If variations occur at any time 
in any of the categories of care, rationale must be docu- 
mented in the progress notes. 

For example, with the sample CPC presented, the 
nurse case manager may admit the client into the de- 
toxification center. The nurse contacts the psychiatrist 
to inform him or her of the admission. The psychia- 
trist performs additional assessments to determine 
if other consultations are required. The psychia- 
trist also writes the orders for the initial diagnostic 

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work-up and medication regimen. Within 24 hours, 
the interdisciplinary team meets to decide on other 
categories of care, to complete the CPC, and to make 
individual care assignments from the CPC. This par- 
ticular sample CPC relies heavily on nursing care 
of the client through the critical withdrawal period. 
However, other problems for the same client, such as 
imbalanced nutrition, impaired physical mobility, or 
spiritual distress, may involve other members of the 

team to a greater degree. Each member of the team 
stays in contact with the nurse case manager regard- 
ing individual assignments. Ideally, team meetings are 
held daily or every other day to review progress and 
modify the plan as required. 

CPCs can be standardized because they are intend- 
ed to be used with uncomplicated cases. A CPC can be 
viewed as protocol for various clients with problems 
for which a designated outcome can be predicted. 

Table 7-2 

Sample Critical Pathway of Care for Client in Alcohol Withdrawal 

Estimated Length of Stay: 7 Days — Variations From Designated Pathway Should Be Documented in Progress Notes 

and Categories 
of Care 


Goals and/or 


Goals and/ 
or Actions 



Risk for injury 
related to CNS 

Day 7 

Client shows no 
evidence of in- 
jury obtained 
during ETOH 




Assess need for: 

Day 7 

Discharge with 
as required 

Diagnostic studies 


Blood alcohol 

Drug screen 

(urine and 


Chest x-ray 


Repeat of 
selected diag- 
nostic studies 
as necessary 

Additional assessments 



Day 2-3 

VSq8h if stable 

Day 4-7 

VS bid; remain 

Day 1-5 


Day 6 




Restraints prn 
for client 


Assess with- 
high blood 
insomnia, hal- 

Day 4 

decrease in 

Day 7 

absence of 



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Table 7-2 

Sample Critical Pathway of Care for Client in Alcohol Withdrawal -cont'd 

Estimated Length of Stay: 7 Days — Variations From Designated Pathway Should Be Documented in Progress Notes 


and Categories 


Goals and/or 


Goals and/ 



of Care 




or Actions 





* Librium 200 
mg in di- 

Day 3 

Librium 120 mg 
in divided 

Day 5 
Day 6 

Librium 40 mg 
DC Librium 

Day 2 

vided doses 
Librium 160 mg 
in divided 

Day 4 

Librium 80 mg 
in divided 

Day 7 

Discharge; no 

Day 1-6 
Day 1-7 

Librium prn 
Maalox ac & hs 

* NOTE: 

Some physi- 
cians may 
elect to use 
Serax or 
Tegretol in 
the detoxifica- 
tion process 

Client education 

Day 5 

Discuss goals of 
AA and need 
for outpatient 

Day 7 

Discharge with 
regarding AA 
or outpatient 

Abbreviations: AA, Alcoholics Anonymous; ac, before meal; bid, twice a day; DC, discontinue; ECG, electrocardiogram; 
ETOH, alcohol; hs, bedtime; I&O, intake and output; q4h, every 4 hours; q8h, every 8 hours; VS, vital signs. 


Based on the definition of mental health set forth in 
Chapter 1 , the role of the nurse in psychiatry focuses on 
helping the client successfully adapt to stressors within 
the environment. Goals are directed toward changes in 
thoughts, feelings, and behaviors that are age appropri- 
ate and congruent with local and cultural norms. 

Therapy within the psychiatric setting is very often 
team, or interdisciplinary, oriented. Therefore, it is 
important to delineate nursing's involvement in the 
treatment regimen. Nurses are indeed valuable mem- 
bers of the team. Having progressed beyond the role 
of custodial caregiver in the psychiatric setting, nurses 
now provide services that are defined within the scope 
of nursing practice. Nursing diagnosis is helping to 
define these nursing boundaries, providing the degree 
of autonomy and professionalism that has for so long 
been unrealized. 

For example, a newly admitted client with the medi- 
cal diagnosis of schizophrenia may be demonstrating 
the following behaviors: 

• Inability to trust others 

• Verbalizing hearing voices 

• Refusing to interact with staff and peers 

• Expressing a fear of failure 

• Poor personal hygiene 

From these assessments, the treatment team may 
determine that the client has the following problems: 

• Paranoid delusions 

• Auditory hallucinations 

• Social withdrawal 

• Developmental regression 

Team goals would be directed toward the following: 

• Reducing suspiciousness 

• Terminating auditory hallucinations 

• Increasing feelings of self- worth 

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From this team treatment plan, nursing may iden- 
tify the following nursing diagnoses: 

1 . Disturbed sensory perception, auditory (evidenced 
by hearing voices) 

2 . Disturbed thought processes (evidenced by delusions) 

3 . Low self-esteem (evidenced by fear of failure and 
social withdrawal) 

4. Self-care deficit (evidenced by poor personal hygiene) 

Nursing diagnoses are prioritized according to life- 
threatening potential. Maslow's hierarchy of needs is 
a good model to follow in prioritizing nursing diag- 
noses. In this instance, disturbed sensory perception 
(auditory) is identified as the priority nursing diagnosis 
because the client may be hearing voices that command 
him or her to harm self or others. Psychiatric nursing, 
regardless of the setting — hospital (inpatient or outpa- 
tient), office, home, community — is goal-directed care. 
The goals (or expected outcomes) are client oriented, 
are measurable, and focus on resolution of the problem 
(if this is realistic) or on a more short-term outcome (if 
resolution is unrealistic). For example, in the previous 
situation, expected outcomes for the identified nursing 
diagnoses might be as follows: 

Client Will: 

• Demonstrate trust in one staff member within 3 days. 

• Verbalize understanding that the voices are not real 
(not heard by others) within 5 days. 

• Complete one simple craft project within 5 days. 

• Take responsibility for own self-care and perform 
activities of daily living independently by time of 

Nursing's contribution to the interdisciplinary 
treatment regimen will focus on establishing trust on 
a one-to-one basis (thus reducing the level of anxi- 
ety that is promoting hallucinations), giving positive 
feedback for small day-to-day accomplishments in an 
effort to build self-esteem, and assisting with and en- 
couraging independent self-care. These interventions 
describe independent nursing actions and goals that are 
evaluated apart from, while also being directed toward 
achievement of, the team's treatment goals. 

In this manner of collaboration with other team 
members, nursing provides a service that is unique and 
based on sound knowledge of psychopathology, scope 
of practice, and legal implications of the role. Although 
there is no dispute that "following doctor's orders" 
continues to be accepted as a priority of care, nursing 
intervention that enhances achievement of the overall 
goals of treatment is being recognized for its important 
contribution. The nurse who administers a medication 

prescribed by the physician to decrease anxiety may 
also choose to stay with the anxious client and offer 
reassurance of safety and security, thereby providing 
an independent nursing action that is distinct from, yet 
complementary to, the medical treatment. 


Concept mapping is a diagrammatic teaching and 
learning strategy that allows students and faculty to 
visualize interrelationships between medical diagnoses, 
nursing diagnoses, assessment data, and treatments. 
The concept map care plan is an innovative approach 
to planning and organizing nursing care. Basically, 
it is a diagram of client problems and interventions. 
Compared to the commonly used column format care 
plans, concept map care plans are more succinct. They 
are practical, realistic, and time saving, and they serve 
to enhance critical-thinking skills and clinical reason- 
ing ability. 

The nursing process is the foundation for developing 
and using the concept map care plan, just as it is with 
all types of nursing care plans. Client data are collected 
and analyzed, nursing diagnoses are formulated, out- 
come criteria are identified, nursing actions are planned 
and implemented, and the success of the interventions 
in meeting the outcome criteria is evaluated. 

The concept map care plan may be presented in its 
entirety on one page, or the assessment data and nurs- 
ing diagnoses may appear in diagram format on one 
page, with outcomes, interventions, and evaluation 
written on a second page. Alternatively, the diagram 
may appear in circular format, with nursing diagnoses 
and interventions branching off the "client" in the 
center of the diagram. Or, it may begin with the "cli- 
ent" at the top of the diagram, with branches emanat- 
ing in a linear fashion downward. 

As stated previously, the concept map care plan is 
based on the components of the nursing process. Ac- 
cordingly, the diagram is assembled in the nursing 
process stepwise fashion, beginning with the client 
and his or her reason for needing care, nursing diag- 
noses with subjective and objective clinical evidence 
for each, nursing interventions, and outcome criteria 
for evaluation. 

Figure 7-2 presents one example of a concept map 
care plan. It is assembled for the hypothetical client 
with schizophrenia discussed in the previous section, 

*Content in this section is adapted from Doenges, Moorhouse, 
: Murr (2008), and Schuster (2008). 

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• Delusional 

• Suspiciousness 


• Verbalizes 
hearing voices 

• Listening pose 

Nsg Dx: 





• Social 

• Expresses fear 
of failure 

Nsg Dx: 

Disturbed Sensory 





• Offensive 
body odor 

• Soiled 

• Unkempt 

Nursing Actions: 

• Don't whisper to 
others in client's 

• Serve food family style 

• Mouth checks for meds 

• Cautious with touch 

• Use same staff 

• Meet client needs and 
keep promises to 
promote trust 

Nursing Actions: 

• Observe for signs of 

• Cautious with touch 

• Use "the voices" instead 
of "they" when asking 
for content of 

• Use distraction to bring 
client back to reality 

Nsg Dx: 

Low Self-Esteem 



Nursing Actions: 

• Spend time with client 
and develop trust 

• Attend groups with client 
at first, to offer support 

• Encourage simple 
methods of achievement 

• Teach effective com- 
munication techniques 

• Encourage verbalization 
of fears 



Nsg Dx: 

Self-Care Deficit 

Nursing Actions: 

• Encourage indepen- 
dence in ADLs, but 
intervene as needed 

• Offer recognition and 
positive reinforcement 
for independent 

FIGURE 7-2 Concept map care plan. 

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"Applying the Nursing Process in the Psychiatric Set- 
ting." Different colors may be used in the diagram 
to designate various components of the care plan. 
Connecting lines are drawn between components 
to indicate any relationships that exist. For example, 
there may be a relationship between two nursing di- 
agnoses (e.g., between the nursing diagnoses of pain 
or anxiety and disturbed sleep pattern). A line between 
these nursing diagnoses should be drawn to show the 

Concept map care plans allow for a great deal of 
creativity on the part of the user and permit viewing 
the "whole picture" without generating a great deal of 
paperwork. Because they reflect the steps of the nurs- 
ing process, concept map care plans also are valuable 
guides for documentation of client care. Doenges, 
Moorhouse, & Murr (2008) state: 

As students, you are asked to develop plans of care 
that often contain more detail than what you see in 
the hospital plans of care. This is to help you learn 
how to apply the nursing process and create indi- 
vidualized client care plans. However, even though 
much time and energy may be spent focusing on 
filling the columns of traditional clinical care plan 
forms, some students never develop a holistic view 
of their clients and fail to visualize how each client 
need interacts with other identified needs. A new 
technique or learning tool [concept mapping] has 
been developed to assist you in visualizing 
the linkages, enhance your critical thinking skills, 
and facilitate the creative process of planning 
client care. (p. 35) 


Equally as important as using the nursing process in 
the delivery of care is the written documentation that 
it has been used. Some contemporary nursing leaders 
are advocating that, with solid standards of practice 
and procedures in place within the institution, nurses 
need only chart when there has been a deviation in 
the care as outlined by that standard. This method of 
documentation, known as charting by exception, is 
not widely accepted, as many legal decisions are still 
based on the precept that "if it was not charted, it was 
not done." 

Because nursing process and nursing diagnosis are 
mandated by nursing practice acts in some states, doc- 
umentation of their use is being considered in those 
states as evidence in determining certain cases of 
negligence by nurses. Some health-care organization 

accrediting agencies also require that nursing process 
be reflected in the delivery of care. Therefore, docu- 
mentation must bear written testament to the use of 
the nursing process. 

A variety of documentation methods can be used 
to reflect use of the nursing process in the delivery 
of nursing care. Three examples are presented here: 
problem-oriented recording (POR); Focus Charting®; 
and the problem, intervention, evaluation (PIE) sys- 
tem of documentation. 

Problem-Oriented Recording 

Problem-oriented recording (POR) follows the sub- 
jective, objective, assessment, plan, implementation, 
and evaluation (SOAPIE) format. It has as its basis a list 
of problems. When it is used in nursing, the problems 
(nursing diagnoses) are identified on a written plan of 
care, with appropriate nursing interventions described 
for each. Documentation written in the SOAPIE for- 
mat includes the following: 

S = Subjective data: Information gathered from what the 
client, family, or other source has said or reported. 

= Objective data: Information gathered by direct 
observation of the person performing the assess- 
ment; may include a physiological measurement 
such as blood pressure or a behavioral response such 
as affect. 

A = Assessment: The nurse's interpretation of the sub- 
jective and objective data. 

P = Plan: The actions or treatments to be carried out 
(may be omitted in daily charting if the plan is clear- 
ly explained in the written nursing care plan and no 
changes are expected). 

1 = Intervention: Those nursing actions that were ac- 

tually carried out. 
E = Evaluation of the problem following nursing in- 
tervention (some nursing interventions cannot be 
evaluated immediately, so this section may be op- 

Table 7-3 shows how POR corresponds to the steps 
of the nursing process. 

Following is an example of a three-column docu- 
mentation in the POR format. 


Date/Time Problem Progress Notes 

6-22-09 Social S: States he does not want to 

1000 isolation sit with or talk to others; 

"they frighten me." 

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O: Stays in room alone unless 
strongly encouraged to come 
out; no group involvement; 
at times listens to group con- 
versations from a distance 
but does not interact; some 
hypervigilance and scanning 

A: Inability to trust; panic 
level of anxiety; delusional 

I: Initiated trusting relation- 
ship by spending time alone 
with the client; discussed his 
feelings regarding interac- 
tions with others; accompa- 
nied client to group activities; 
provided positive feedback 
for voluntarily participating 
in assertiveness training. 

Focus Charting 

Another type of documentation that reflects use of the 
nursing process is Focus Charting®. Focus Charting 
differs from POR in that the main perspective has been 
changed from "problem" to "focus," and data, action, 
and response (DAR), has replaced SOAPIE. 

Lampe (1985) suggests that a focus for documenta- 
tion can be any of the following: 

1 . Nursing diagnosis 

2 . Current client concern or behavior 

3 . Significant change in the client status or behavior 

4. Significant event in the client's therapy 

The focus cannot be a medical diagnosis. The docu- 
mentation is organized in the format of DAR. These 
categories are defined as follows: 

D = Data: Information that supports the stated focus 
or describes pertinent observations about the client. 

A = Action: Immediate or future nursing actions that 
address the focus, and evaluation of the present care 
plan along with any changes required. 

R = Response: Description of client's responses to any 
part of the medical or nursing care. 

Table 7-4 shows how Focus Charting corresponds to 
the steps of the nursing process. Following is an example 
of a three-column documentation in the DAR format. 


Date/Time Focus 

Progress Notes 

6-22-09 Social D: States he does not want 

1 000 isolation to sit with or talk to others; 

related to they "frighten" him; stays in 
mistrust, room alone unless strongly 
panic encouraged to come out; 

anxiety, no group involvement; at 

delusions times listens to group con- 
versations from a distance, 
but does not interact; some 
hypervigilance and scan- 
ning noted. 

A: Initiated trusting rela- 
tionship by spending time 
alone with client; discussed 
his feelings regarding in- 
teractions with others; ac- 
companied client to group 
activities; provided positive 
feedback for voluntarily 
participating in assertive- 
ness training. 

R: Cooperative with thera- 
py; still acts uncomfortable 
in the presence of a group 
of people; accepted posi- 
tive feedback from nurse. 

Table 7 

Validation of the Nursing Process With Problem-Oriented Recording 

Problem-Oriented Recording 

What Is Recorded 

Nursing Process 

S and O (Subjective and Objective data) 

Verbal reports to, and direct observation 
and examination by, the nurse 


A (Assessment) 

Nurse's interpretation of S and O 

Diagnosis and outcome identification 

P (Plan) Omitted in charting if written 
plan describes care to be given 

Description of appropriate nursing actions 
to resolve the identified problem 


I (Intervention) 

Description of nursing actions actually 
carried out 


E (Evaluation) 

A reassessment of the situation to 
determine results of nursing actions 


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Table 7 

Validation of the Nursing Process With Focus Charting 

Focus Charting 

What Is Recorded 

Nursing Process 

D (Data) 

Information that supports the stated focus or describes perti- 
nent observations about the client. 



A nursing diagnosis; current client concern or behavior; 
significant change in client status; significant event in the 
client's therapy. NOTE: If outcome appears on written 
care plan, it need not be repeated in daily documentation 
unless a change occurs. 

Diagnosis and outcome identification 

A (Action) 

Immediate or future nursing actions that address the focus; 
appraisal of the care plan along with any changes required. 

Plan and implementation 

R (Response) 

Description of client responses to any part of the medical or 
nursing care. 


The PIE Method 

The problem, intervention, evaluation (PIE) method, 
or more specifically "APIE" (assessment, problem, 
intervention, evaluation), is a systematic method of 
documenting nursing process and nursing diagnosis. A 
problem-oriented system, PIE charting uses accom- 
panying flow sheets that are individualized by each in- 
stitution. Criteria for documentation are organized in 
the following manner: 

A = Assessment: A complete client assessment is con- 
ducted at the beginning of each shift. Results are 
documented under this section in the progress notes. 
Some institutions elect instead to use a daily client 
assessment sheet designed to meet specific needs 
of the unit. Explanation of any deviation from the 
norm is included in the progress notes. 

P = Problem: A problem list, or list of nursing diag- 
noses, is an important part of the APIE method of 
charting. The name or number of the problem be- 
ing addressed is documented in this section. 

I = Intervention: Nursing actions are performed, di- 
rected at resolution of the problem. 

E = Evaluation: Outcomes of the implemented inter- 
ventions are documented, including an evaluation 
of client responses to determine the effectiveness of 
nursing interventions and the presence or absence 
of progress toward resolution of a problem. 

Table 7-5 shows how APIE charting corresponds to 
the steps of the nursing process. Following is an ex- 
ample of a three-column documentation in the APIE 


Date/Time Problem Progress Notes 

6-22-09 Social A: States he does not want 

1000 isolation to sit with or talk to others; 

they "frighten" him; stays in 
room alone unless strongly 
encouraged to come out; 
no group involvement; at 
times listens to group con- 
versations from a distance 

Table 7 

Validation of the Nursing Process With APIE Method 

APIE Charting 

What Is Recorded 

Nursing Process 

A (Assessment) 
P (Problem) 

I (Intervention) 
E (Evaluation) 

Subjective and objective data about the client that are 
gathered at the beginning of each shift 

Name (or number) of nursing diagnosis being addressed 
from written problem list, and identified outcome for 
that problem. NOTE: If outcome appears on written 
care plan, it need not be repeated in daily documenta- 
tion unless a change occurs. 

Nursing actions performed, directed at problem resolu- 

Appraisal of client responses to determine effectiveness 
of nursing interventions 


Diagnosis and outcome identification 

Plan and implementation 


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but does not interact; some 
hypervigilance and scanning 

P: Social isolation related to 
inability to trust, panic level 
of anxiety, and delusional 

I: Initiated trusting relation- 
ship by spending time alone 
with client; discussed his 
feelings regarding interac- 
tions with others; accompa- 
nied client to group activities; 
provided positive feedback 
for voluntarily participating 
in assertiveness training. 
E: Cooperative with ther- 
apy; still uncomfortable in 
the presence of a group of 
people; accepted positive 
feedback from nurse. 

Electronic Documentation 

Most health-care facilities have implemented — or are 
in the process of implementing — some type of elec- 
tronic health record (EHR) or electronic documen- 
tation system. EHRs have been shown to improve 
both the quality of client care and the efficiency of the 
health-care system (Hopper & Ames, 2004). In 2003, 
the U.S. Department of Health and Human Services 
commissioned the Institute of Medicine (IOM) to 
study the capabilities of an EHR system. The IOM 
identified a set of eight core functions that EHR sys- 
tems should perform in the delivery of safer, higher 
quality, and more efficient health care. These eight 
core capabilities include the following (Tang, 2003): 

• Health information and data: EHRs would pro- 
vide more rapid access to important patient in- 
formation (e.g., allergies, laboratory test results, a 
medication list, demographic information, and clin- 
ical narratives), thereby improving care providers' 
ability to make sound clinical decisions in a timely 

• Results management: Computerized results of all 
types (e.g., laboratory test results, radiology proce- 
dure result reports) can be accessed more easily by 
the provider at the time and place they are needed. 

• Order entry/order management: Computer-based 
order entries improve workflow processes by elimi- 
nating lost orders and ambiguities caused by illegible 
handwriting, generating related orders automatically, 

monitoring for duplicate orders, and improving the 
speed with which orders are executed. 

• Decision support: Computerized decision support 
systems enhance clinical performance for many 
aspects of health care. Using reminders and prompts, 
improvement in regular screenings and other pre- 
ventive practices can be accomplished. Other as- 
pects of health-care support include identifying 
possible drug interactions and facilitating diagnosis 
and treatment. 

• Electronic communication and connectivity: 
Improved communication among care associates, 
such as medicine, nursing, laboratory, pharmacy, 
and radiology, can enhance client safety and quality 
of care. Efficient communication among providers 
improves continuity of care, allows for more time- 
ly interventions, and reduces the risk of adverse 

• Patient support: Computer-based interactive cli- 
ent education, self-testing, and self-monitoring have 
been shown to improve control of chronic illnesses. 

• Administrative processes: Electronic scheduling 
systems (e.g., for hospital admissions and outpatient 
procedures) increase the efficiency of health- care 
organizations and provide more timely service to 

• Reporting and population health management: 
Health-care organizations are required to report 
health-care data to government and private sectors 
for patient safety and public health. Uniform elec- 
tronic data standards facilitate this process at the 
provider level, reduce the associated costs, and in- 
crease the speed and accuracy of the data reported. 

Table 7-6 lists some of the advantages and disadvan- 
tages of paper records and EHRs. 


The nursing process provides a methodology by 
which nurses may deliver care using a systematic, 
scientific approach. 

The focus of nursing process is goal directed and 
based on a decision-making or problem-solving mod- 
el, consisting of six steps: assessment, diagnosis, out- 
come identification, planning, implementation, and 

Assessment is a systematic, dynamic process by 
which the nurse, through interaction with the cli- 
ent, significant others, and health-care providers, 
collects and analyzes data about the client. 

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Table 7-6 

Advantages and Disadvantages of Paper Records and EHRs 




• People know how to use it. 

• It is fast for current practice. 

• It is portable. 

• It is nonbreakable. 

• It accepts multiple data types, such as graphs, photographs, 
drawings, and text. 

• Legal issues and costs are understood. 


• It can be lost. 

• It is often illegible and incomplete. 

• It has no remote access. 

• It can be accessed by only one person at a time. 

• It is often disorganized. 

• Information is duplicated. 

• It is hard to store. 

• It is difficult to research, and continuous quality improvement 
is laborious. 

• Same client has separate records at each facility (physician's of- 
fice, hospital, home care). 

• Records are shared only through hard copy. 


Can be accessed by multiple providers from remote sites. 
Facilitates communication between disciplines. 
Provides reminders about completing information. 
Provides warnings about incompatibilities of medications or 
variances from normal standards. 
Reduces redundancy of information. 
Requires less storage space and more difficult to lose. 
Easier to research for audits, quality assurance, and epidemio- 
logical surveillance. 

Provides immediate retrieval of information (e.g., test results). 
Provides links to multiple databases of health-care knowledge, 
thus providing diagnostic support. 
Decreases charting time. 
Reduces errors due to illegible handwriting. 
Facilitates billing and claims procedures. 


Excessive expense to initiate the system. 

Substantial learning curve involved for new users; training and 

retraining required. 

Stringent requirements to maintain security and confidentiality. 

Technical difficulties are possible. 

Legal and ethical issues involving privacy and access to client 


Requires consistent use of standardized terminology to support 

information sharing across wide networks. 

*From Young, K.M. (2009). Nursing informatics. In J.T. Catalano (Ed.), 
Philadelphia: FA. Davis. With permission. 

Today's issues, tomorrow's trends (5th ed.). 

Nursing diagnoses are clinical judgments about in- 
dividual, family, or community responses to actual 
or potential health problems/life processes. 
Outcomes are measurable, expected, patient- focused 
goals that translate into observable behaviors. 
Evaluation is the process of determining both the 
client's progress toward the attainment of expected 
outcomes and the effectiveness of nursing care. 
The psychiatric nurse uses the nursing process to 
assist clients adapt successfully to stressors within 
the environment. 

The nurse serves as a valuable member of the inter- 
disciplinary treatment team, working both independ- 
ently and cooperatively with other team members. 
Case management is an innovative model of care de- 
livery that serves to provide quality client care while 
controlling health-care costs. Critical pathways of 
care (CPCs) serve as the tools for provision of care 
in a case management system. 

Nurses may serve as case managers, who are respon- 
sible for negotiating with multiple health-care pro- 
viders to obtain a variety of services for the client. 

I Concept mapping is a diagrammatic teaching and 
learning strategy that allows students and faculty to 
visualize interrelationships between medical diag- 
noses, nursing diagnoses, assessment data, and treat- 
ments. The concept map care plan is an innovative 
approach to planning and organizing nursing care. 
Nurses must document that the nursing process has 
been used in the delivery of care. Three methods of 
documentation that reflect use of the nursing proc- 
ess are problem-oriented recording (POR); Focus 
Charting; and the problem, intervention, evaluation 
(PIE) method. 

Many health- care facilities have implemented the 
use of electronic health records (EHR) or electronic 
documentation systems. EHRs have been shown to 
improve both the quality of client care and the ef- 
ficiency of the health- care system. 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 

1 . The nurse is using nursing process to care for a suicidal client. Which of the following nursing 
actions is a part of the assessment step of the nursing process? 

a. Identifies nursing diagnosis: Risk for suicide 

b. Notes client's family reports recent suicide attempt 

c. Prioritizes the necessity for maintaining a safe environment for the client 

d. Obtains a short-term contract from the client to seek out staff if client is feeling suicidal 

2 . The nurse is using nursing process to care for a suicidal client. Which of the following nursing 
actions is a part of the diagnosis step of the nursing process? 

a. Identifies nursing diagnosis: Risk for suicide 

b. Notes client's family reports recent suicide attempt 

c. Prioritizes the necessity for maintaining a safe environment for the client 

d. Obtains a short-term contract from the client to seek out staff if client is feeling suicidal 

3 . The nurse is using nursing process to care for a suicidal client. Which of the following nursing 
actions is a part of the outcome identification step of the nursing process? 

a. Prioritizes the necessity for maintaining a safe environment for the client 

b. Determines if nursing interventions have been appropriate to achieve desired results 

c. Obtains a short-term contract from the client to seek out staff if client is feeling suicidal 

d. Establishes goal of care: Client will not harm self during hospitalization 

4. The nurse is using nursing process to care for a suicidal client. Which of the following nursing 
actions is a part of the planning step of the nursing process? 

a. Prioritizes the necessity for maintaining a safe environment for the client 

b. Determines if nursing interventions have been appropriate to achieve desired results 

c. Obtains a short-term contract from the client to seek out staff if client is feeling suicidal 

d. Establishes goal of care: Client will not harm self during hospitalization 

5 . The nurse is using nursing process to care for a suicidal client. Which of the following nursing 
actions is a part of the implementation step of the nursing process? 

a. Prioritizes the necessity for maintaining a safe environment for the client 

b. Determines if nursing interventions have been appropriate to achieve desired results 

c. Obtains a short-term contract from the client to seek out staff if client is feeling suicidal 

d. Establishes goal of care: Client will not harm self during hospitalization 

6. The nurse is using nursing process to care for a suicidal client. Which of the following nursing 
actions is a part of the evaluation step of the nursing process? 

a. Prioritizes the necessity for maintaining a safe environment for the client 

b. Determines if nursing interventions have been appropriate to achieve desired results 

c. Obtains a short-term contract from the client to seek out staff if client is feeling suicidal 

d. Establishes goal of care: Client will not harm self during hospitalization 

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7. S.T. is a 15 -year-old girl who has just been admitted to the adolescent psychiatric unit with 

a diagnosis of anorexia nervosa. She is 5 '5" tall and weighs 82 pounds. She was elected to the 
cheerleading squad for the fall but states that she is not as good as the others on the squad. The 
treatment team has identified the following problems: refusal to eat, occasional purging, refusing 
to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses 
would be appropriate for S.T.? Select all that apply. 

a. Social Isolation 

b. Disturbed Body Image 

c. Low S elf-Esteem 

d. Imbalanced Nutrition: Less than body requirements 

8. S.T. is a 15 -year-old girl who has just been admitted to the adolescent psychiatric unit with 
a diagnosis of anorexia nervosa. She is 5'5" tall and weighs 82 pounds. She was elected to the 
cheerleading squad for the fall but states that she is not as good as the others on the squad. The 
treatment team has identified the following problems: refusal to eat, occasional purging, refusing 
to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses 
would be the priority diagnosis for S.T.? 

a. Social Isolation 

b. Disturbed Body Image 

c. Low S elf-Esteem 

d. Imbalanced Nutrition: Less than body requirements 

9. Nursing diagnoses are prioritized according to which of the following? 

a. Degree of potential for resolution 

b. Legal implications associated with nursing intervention 

c. Life-threatening potential 

d. Client and family requests 

10. Which of the following describe advantages to electronic health records (EHRs)? Select all that 

a. It reduces redundancy of information. 

b. It reduces issues regarding privacy. 

c. It decreases charting time. 

d. It facilitates communication between disciplines. 


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American Nurses Association (ANA). (2004). Nursing: Scope and 
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American Nurses Association (ANA), American Psychiatric Nurses 
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Mental Health Nurses (ISPN). (2007). Psychiatric-mental health 
nursing: Scope and standards of practice. Silver Spring, MD: ANA. 

American Psychiatric Association (APA). (2000). Diagnosis and statis- 
tical manual of mental disorders (4th ed.) Text revision. Washington, 
DC: American Psychiatric Publishing. 

Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2008). Nursing 
diagnosis manual: Planning, individualizing, and documenting client 
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mental state: A practical method for grading the cognitive state 
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Johnson, M., Bulechek, G., Dochterman, J.M., Maas, M., 

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interventions (2nd ed.). New York: Elsevier. 
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H A P T E R 

Milieu Therapy— 

The Therapeutic 
















therapeutic community 


milieu therapy 


After reading this chapter, the student will be able to: 

1. Define milieu therapy. 

2. Explain the goal of therapeutic 
community /milieu therapy. 

3. Identify seven basic assumptions of a 
therapeutic community. 

4. Discuss conditions that characterize a 
therapeutic community. 

5. Identify the various therapies that may 
be included within the program of the 
therapeutic community and the health- 
care workers that make up the interdisci- 
plinary treatment team. 

6. Describe the role of the nurse on the inter- 
disciplinary treatment team. 


Please read the chapter and answer the following questions. 

1. How are unit rules established in a thera- 
peutic community setting? 

2. Which member of the interdisciplinary 
treatment team has a focus on rehabilita- 
tion and vocational training? 

3. How are client responsibilities assigned 
in the therapeutic community setting? 

4. Which member of the interdisciplinary 
treatment team serves as leader? 


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Standard 5 c of the Psychiatric-Mental Health Nursing: 
Scope and Standards of Practice (American Nurses Associa- 
tion [ANA], 2007) states that "The psychiatric-mental 
health nurse provides, structures, and maintains a safe 
and therapeutic environment in collaboration with pa- 
tients, families, and other health care clinicians" (p. 39). 
This chapter defines and explains the goal of milieu 
therapy. The conditions necessary for a therapeutic 
environment are discussed, and the roles of the various 
health-care workers within the interdisciplinary team 
are delineated. An interpretation of the nurse's role in 
milieu therapy is included. 


The word milieu is French for "middle." The English 
translation of the word is "surroundings or environ- 
ment." In psychiatry, therapy involving the milieu, or 
environment, may be called milieu therapy, thera- 
peutic community, or therapeutic environment. 
The goal of milieu therapy is to manipulate the en- 
vironment so that all aspects of the client's hospital 
experience are considered therapeutic. Within this 
therapeutic community setting, the client is expected 
to learn adaptive coping, interaction, and relation- 
ship skills that can be generalized to other aspects of 
his or her life. 



Milieu therapy came into its own during the 1960s 
through the early 1980s. During this period, psychi- 
atric inpatient treatment provided sufficient time to 
implement programs of therapy that were aimed at 
social rehabilitation. Nursing's focus of establishing 
interpersonal relationships with clients fit well within 


Milieu Therapy 

A scientific structuring of the environment in order 
to effect behavioral changes and to improve the 
psychological health and functioning of the indi- 
vidual (Skinner, 1979). 

this concept of therapy. Patients were encouraged to 
be active participants in their therapy, and individual 
autonomy was emphasized. 

The current focus of inpatient psychiatric care has 
changed. Hall (1995) stated: 

Care in inpatient psychiatric facilities can now be 
characterized as short and biologically based. By 
the time patients have stabilized enough to benefit 
from the socialization that would take place in a 
milieu as treatment program, they [often] have been 
discharged, (p. 51) 

Although strategies for milieu therapy are still 
used, they have been modified to conform to the 
short-term approach to care or to outpatient treat- 
ment programs. Some programs (e.g., those for chil- 
dren and adolescents, clients with substance addic- 
tions, and geriatric clients) have successfully adapted 
the concepts of milieu treatment to their specialty 
needs (Bowler, 1991; DeSocio, Bowllan, & Staschak, 
1997;Whall, 1991). 

Echternacht (2001) suggests that more empha- 
sis should be placed on unstructured components 
of milieu therapy. She describes the unstructured 
components as a multitude of complex interactions 
between clients, staff, and visitors that occur around 
the clock. Echternacht calls these interactions "fluid 
group work." They involve spontaneous opportuni- 
ties within the milieu environment for the psychiatric 
nurse to provide "on-the-spot therapeutic interven- 
tions designed to enhance socialization competency 
and interpersonal relationship awareness. Emphasis is 
on social skills and activities in the context of interper- 
sonal interactions" (p. 40). With fluid group work, the 
nurse applies psychotherapeutic knowledge and skills 
to brief clinical encounters that occur spontaneously 
in the therapeutic milieu setting. Echternacht (2001) 
believes that by using these techniques, nurses can "re- 
claim their milieu therapy functions in the midst of a 
changing health care environment" (p. 40). 

Many of the original concepts of milieu therapy are 
presented in this chapter. It is important to remem- 
ber that a number of modifications to these concepts 
have been applied in practice for use in a variety of 


Skinner (1979) outlined seven basic assumptions on 
which a therapeutic community is based: 

1. The health in each individual is to be real- 
ized and encouraged to grow: All individuals are 

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considered to have strengths as well as limitations. 
These healthy aspects of the individual are identified 
and serve as a foundation for growth in the person- 
ality and in the ability to function more adaptively 
and productively in all aspects of life. 

2. Every interaction is an opportunity for thera- 
peutic intervention: Within this structured set- 
ting, it is virtually impossible to avoid interpersonal 
interaction. The ideal situation exists for clients to 
improve communication and relationship develop- 
ment skills. Learning occurs from immediate feed- 
back of personal perceptions. 

3. The client owns his or her own environment: 
Clients make decisions and solve problems related 
to government of the unit. In this way, personal 
needs for autonomy as well as needs that pertain to 
the group as a whole are fulfilled. 

4. Each client owns his or her behavior: Each in- 
dividual within the therapeutic community is ex- 
pected to take responsibility for his or her own 

5. Peer pressure is a useful and a powerful tool: 
Behavioral group norms are established through 
peer pressure. Feedback is direct and frequent, so 
that behaving in a manner acceptable to the other 
members of the community becomes essential. 

6. Inappropriate behaviors are dealt with as they 
occur: Individuals examine the significance of their 
behavior, look at how it affects other people, and 
discuss more appropriate ways of behaving in cer- 
tain situations. 

7. Restrictions and punishment are to be avoided: 
Destructive behaviors can usually be controlled 
with group discussion. However, if an individual 
requires external controls, temporary isolation is 
preferred over lengthy restriction or other harsh 



In a therapeutic community setting, everything that 
happens to the client, or within the client's environ- 
ment, is considered to be part of the treatment pro- 
gram. The community setting is the foundation for the 
program of treatment. Community factors — such as 
social interactions, the physical structure of the treat- 
ment setting, and schedule of activities — may generate 
negative responses from some clients. These stressful 
experiences are used as examples to help the client 
learn how to manage stress more adaptively in real-life 

Under what conditions, then, is a hospital environ- 
ment considered therapeutic? A number of criteria 
have been identified: 

1 . Basic physiological needs are fulfilled: As Maslow 
(1968) suggested, individuals do not move to higher 
levels of functioning until the basic biological needs 
for food, water, air, sleep, exercise, elimination, shel- 
ter, and sexual expression have been met. 

2 . The physical facilities are conducive to achieve- 
ment of the goals of therapy: Space is provided 
so that each client has sufficient privacy, as well as 
physical space, for therapeutic interaction with oth- 
ers. Furnishings are arranged to present a homelike 
atmosphere — usually in spaces that accommodate 
communal living, dining, and activity areas — for 
facilitation of interpersonal interaction and com- 

3. A democratic form of self-government exists: 
In the therapeutic community, clients participate in 
the decision making and problem solving that af- 
fect the management of the treatment setting. This 
is accomplished through regularly scheduled com- 
munity meetings. These meetings are attended by 
staff and clients, and all individuals have equal input 
into the discussions. At these meetings, the norms 
and rules and behavioral limits of the treatment set- 
ting are set forth. This reinforces the democratic 
posture of the treatment setting, because these are 
expectations that affect all clients on an equal basis. 
An example might be the rule that no client may 
enter a room being occupied by a client of the op- 
posite sex. Consequences of violating the rules are 

Other issues that may be discussed at the com- 
munity meetings include those with which certain 
clients have some disagreements. A decision is then 
made by the entire group in a democratic manner. 
For example, several clients in an inpatient unit may 
disagree with the hours that have been designated for 
watching television on a weekend night. They may 
elect to bring up this issue at a community meet- 
ing and suggest an extension in television-viewing 
time. After discussion by the group, a vote will be 
taken, and clients and staff agree to abide by the ex- 
pressed preference of the majority. Some therapeu- 
tic communities elect officers (usually a president 
and a secretary) who serve for a specified time. The 
president calls the meeting to order, conducts the 
business of discussing old and new issues, and asks 
for volunteers (or makes appointments, alternately, 
so that all clients have a turn) to accomplish the 
daily tasks associated with community living, for 

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example, cleaning the tables after each meal and 
watering plants in the treatment facility. New as- 
signments are made at each meeting. The secretary 
reads the minutes of the previous meeting and takes 
minutes of the current meeting. Minutes are impor- 
tant in the event that clients have a disagreement 
about issues that were discussed at various meet- 
ings. Minutes provide written evidence of decisions 
made by the group. In treatment settings where 
clients have short attention spans or disorganized 
thinking, meetings are brief. Business is generally 
limited to introductions and expectations of the 
here and now. Discussions also may include com- 
ments about a recent occurrence in the group or 
something that has been bothering a member and 
about which he or she has some questions. These 
meetings are usually conducted by staff, although 
all clients have equal input into the discussions. 

All clients are expected to attend the meetings. Ex- 
ceptions are made for times when aspects of therapy 
interfere (e.g., scheduled testing, x-ray examinations, 
electroencephalograms). An explanation is made to 
clients present so that false perceptions of danger are 
not generated by another person's absence. All staff 
members are expected to attend the meetings, unless 
client care precludes their attendance. 

4. Responsibilities are assigned according to cli- 
ent capabilities: Increasing self-esteem is an ulti- 
mate goal of the therapeutic community. Therefore, 
a client should not be set up for failure by being 
assigned a responsibility that is beyond his or her 
level of ability. By assigning clients responsibilities 
that promote achievement, self-esteem is enhanced. 
Consideration must also be given to times during 
which the client will show some regression in the 
treatment regimen. Adjustments in assignments 
should be made in a way that preserves self-esteem 
and provides for progression to greater degrees of 
responsibility as the client returns to a previous lev- 
el of functioning. 

5. A structured program of social and work- 
related activities is scheduled as part of the 
treatment program: Each client's therapeutic pro- 
gram consists of group activities in which interper- 
sonal interaction and communication with other 
individuals are emphasized. Time is also devoted to 
personal problems. Various group activities may be 
selected for clients with specific needs (e.g., an ex- 
ercise group for a person who expresses anger inap- 
propriately, an assertiveness group for a person who 
is passive-aggressive, or a stress-management group 
for a person who is anxious). A structured schedule 

of activities is the major focus of a therapeutic com- 
munity. Through these activities, change in the cli- 
ent's personality and behavior can be achieved. New 
coping strategies are learned, and social skills are 
developed. In the group situation, the client is able 
to practice what he or she has learned to prepare for 
transition to the general community. 
6. Community and family are included in the pro- 
gram of therapy in an effort to facilitate dis- 
charge from treatment: An attempt is made to 
include family members, as well as certain aspects 
of the community that affect the client, in the treat- 
ment program. It is important to keep as many links 
to the client's life outside of therapy as possible. 
Family members are invited to participate in spe- 
cific therapy groups and, in some instances, to share 
meals with the client in the communal dining room. 
Connection with community life may be maintained 
through client group activities, such as shopping, 
picnicking, attending movies, bowling, and visiting 
the zoo. Inpatient clients may be awarded passes 
to visit family or may participate in work-related 
activities, the length of time being determined by 
the activity and the client's condition. These con- 
nections with family and community facilitate the 
discharge process and may help to prevent the client 
from becoming too dependent on the therapy. 


Care for clients in the therapeutic community is direct- 
ed by an interdisciplinary treatment (IDT) team. An 
initial assessment is made by the admitting psychiatrist, 
nurse, or other designated admitting agent who estab- 
lishes a priority of care. The IDT team determines a 
comprehensive treatment plan and goals of therapy and 
assigns intervention responsibilities. All members sign 
the treatment plan and meet regularly to update the 
plan as needed. Depending on the size of the treatment 
facility and scope of the therapy program, members rep- 
resenting a variety of disciplines may participate in the 
promotion of a therapeutic community. For example, 
an IDT team may include a psychiatrist, clinical psy- 
chologist, psychiatric clinical nurse specialist, psychiat- 
ric nurse, mental health technician, psychiatric social 
worker, occupational therapist, recreational therapist, 
art therapist, music therapist, psychodramatist, dieti- 
tian, and chaplain. Table 8-1 provides an explanation of 
responsibilities and educational preparation required 
for these members of the IDT team. 

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Table 8- 

The Interdisciplinary Treatment Team in Psychiatry 

Team Member 


Clinical Psychologist 

Psychiatric Clinical Nurse 

Psychiatric Nurse 

Mental Health Technician 
(also called psychiatric 
aide or assistant or 
psychiatric technician) 

Psychiatric Social Worker 

Occupational Therapist 

Recreational Therapist 

Music Therapist 

Art Therapist 


Serves as the leader of the team. Responsible for diagno- 
sis and treatment of mental disorders. Performs psy- 
chotherapy; prescribes medication and other somatic 

Conducts individual, group, and family therapy. Admin- 
isters, interprets, and evaluates psychological tests that 
assist in the diagnostic process. 

Conducts individual, group, and family therapy. Presents 
educational programs for nursing staff. Provides con- 
sultation services to nurses who require assistance in 
the planning and implementation of care for individual 

Provides ongoing assessment of client condition, both 
mentally and physically. Manages the therapeutic 
milieu on a 24-hour basis. Administers medications. 
Assists clients with all therapeutic activities as required. 
Focus is on one-to-one relationship development. 

Functions under the supervision of the psychiatric nurse. 
Provides assistance to clients in the fulfillment of their 
activities of daily living. Assists activity therapists as re- 
quired in conducting their groups. May also participate 
in one-to-one relationship development. 

Conducts individual, group, and family therapy. Is 

concerned with client's social needs, such as placement, 
financial support, and community requirements. Con- 
ducts in-depth psychosocial history on which the needs 
assessment is based. Works with client and family to 
ensure that requirements for discharge are fulfilled and 
needs can be met by appropriate community resources. 

Works with clients to help develop (or redevelop) inde- 
pendence in performance of activities of daily living. 
Focus is on rehabilitation and vocational training in 
which clients learn to be productive, thereby enhanc- 
ing self-esteem. Creative activities and therapeutic 
relationship skills are used. 

Uses recreational activities to promote clients to redirect 
their thinking or to rechannel destructive energy in 
an appropriate manner. Clients learn skills that can 
be used during leisure time and during times of stress 
following discharge from treatment. Examples include 
bowling, volleyball, exercises, and jogging. Some 
programs include activities such as picnics, swimming, 
and even group attendance at the state fair when it is 
in session. 

Encourages clients in self-expression through music. 
Clients listen to music, play instruments, sing, dance, 
and compose songs that help them get in touch with 
feelings and emotions that they may not be able to 
experience in any other way. 

Uses the client's creative abilities to encourage expression 
of emotions and feelings through artwork. Helps cli- 
ents to analyze their own work in an effort to recognize 
and resolve underlying conflict. 


Medical degree with residency in psychia- 
try and license to practice medicine. 

Doctorate in clinical psychology with 
2- to 3 -year internship supervised by 
a licensed clinical psychologist. State 
license is required to practice. 

Registered nurse with minimum of a 
master's degree in psychiatric nursing. 
Some institutions require certification by 
national credentialing association. 

Registered nurse with hospital diploma, as- 
sociate degree, or baccalaureate degree. 
Some psychiatric nurses have national 

Varies from state to state. Requirements 
include high school education, with 
additional vocational education or on- 
the-job training. Some hospitals hire 
individuals with baccalaureate degree 
in psychology in this capacity. Some 
states require a licensure examination to 

Minimum of a master's degree in social 
work. Some states require additional 
supervision and subsequent licensure by 

Baccalaureate or master's degree in oc- 
cupational therapy. 

Baccalaureate or master's degree in recrea- 
tional therapy. 

Graduate degree with specialty in music 

Graduate degree with specialty in art 


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Table 8-1 

The Interdisciplinary Treatment Team in Psychiatry— cont'd 

Team Member 






Directs clients in the creation of a "drama" that portrays 
real-life situations. Individuals select problems they 
wish to enact, and other clients play the roles of 
significant others in the situations. Some clients are 
able to "act out" problems that they are unable to work 
through in a more traditional manner. All members 
benefit through intensive discussion that follows. 

Plans nutritious meals for all clients. Works on consulting 
basis for clients with specific eating disorders, such as 
anorexia nervosa, bulimia nervosa, obesity, and pica. 

Assesses, identifies, and attends to the spiritual needs of 
clients and their family members. Provides spiritual 
support and comfort as requested by client or family. 
May provide counseling if educational background 
includes this type of preparation. 

Graduate degree in psychology, social 
work, nursing, or medicine with ad- 
ditional training in group therapy 
and specialty preparation to become a 

Baccalaureate or master's degree with 
specialty in dietetics. 

College degree with advanced education in 
theology, seminary, or rabbinical studies. 


Milieu therapy can take place in a variety of inpatient 
and outpatient settings. In the hospital, nurses are gen- 
erally the only members of the IDT team who spend 
time with the clients on a 24-hour basis, and they as- 
sume responsibility for management of the therapeutic 
milieu. In all settings, the nursing process is used for 
the delivery of nursing care. Ongoing assessment, di- 
agnosis, outcome identification, planning, implemen- 
tation, and evaluation of the environment are neces- 
sary for the successful management of a therapeutic 
milieu. Nurses are involved in all day-to-day activities 
that pertain to client care. Suggestions and opinions 
of nursing staff are given serious consideration in the 
planning of care for individual clients. Information 
from the initial nursing assessment is used to create 
the IDT plan. Nurses have input into therapy goals 
and participate in the regular updates and modification 
of treatment plans. 

In some treatment facilities, a separate nursing care 
plan is required in addition to the IDT plan. When 
this is the case, the nursing care plan must reflect diag- 
noses that are specific to nursing and include problems 
and interventions from the IDT plan that have been 
assigned specifically to the discipline of nursing. 

In the therapeutic milieu, nurses are responsible 
for ensuring that clients' physiological needs are met. 
Clients must be encouraged to perform as independ- 
ently as possible in fulfilling activities of daily living. 
However, the nurse must make ongoing assessments to 
provide assistance for those who require it. Assessing 
physical status is an important nursing responsibility 

that must not be overlooked in a psychiatric setting 
that emphasizes holistic care. 

Reality orientation for clients who have disorganized 
thinking or who are disoriented or confused is impor- 
tant in the therapeutic milieu. Clocks with large hands 
and numbers, calendars that give the day and date in 
large print, and orientation boards that discuss daily ac- 
tivities and news happenings can help keep clients ori- 
ented to reality. Nurses should ensure that clients have 
written schedules of activities to which they are as- 
signed and that they arrive at those activities on sched- 
ule. Some clients may require an identification sign on 
their door to remind them which room is theirs. On 
short-term units, nurses who are dealing with psychotic 
clients usually rely on a basic activity or topic that helps 
keep people oriented, for example, showing pictures of 
the hospital where they are housed, introducing peo- 
ple who were admitted during the night, and providing 
name badges with their first name. 

Nurses are responsible for the management of medi- 
cation administration on inpatient psychiatric units. In 
some treatment programs, clients are expected to ac- 
cept the responsibility and request their medication at 
the appropriate time. Although ultimate responsibility 
lies with the nurse, he or she must encourage clients 
to be self-reliant. Nurses must work with the clients 
to determine methods that result in achievement and 
provide positive feedback for successes. 

A major focus of nursing in the therapeutic milieu 
is the one-to-one relationship that grows out of a de- 
veloping trust between client and nurse. Many clients 
with psychiatric disorders have never achieved the abil- 
ity to trust. If this can be accomplished in a relationship 

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with the nurse, the trust may be generalized to other 
relationships in the client's life. Within an atmosphere 
of trust, the client is encouraged to express feelings and 
emotions and to discuss unresolved issues that are cre- 
ating problems in his or her life. 


(§) Developing trust means keeping promises that 
have been made. It means total acceptance of the 
individual as a person, separate from behavior 
that is unacceptable. It means responding to the 
client with concrete behaviors that are under- 
standable to him or her (e.g., "If you are fright- 
ened, I will stay with you"; "If you are cold, I will 
bring you a blanket"; "If you are thirsty, I will bring 
you a drink of water"). 

The nurse is responsible for setting limits on un- 
acceptable behavior in the therapeutic milieu. This 
requires stating to the client in understandable ter- 
minology what behaviors are not acceptable and what 
the consequences will be should the limits be violated. 
These limits must be established, written, and carried 
out by all staff. Consistency in carrying out the conse- 
quences of violation of the established limits is essen- 
tial if the learning is to be reinforced. 

The role of client teacher is important in the psy- 
chiatric area, as it is in all areas of nursing. Nurses 
must be able to assess learning readiness in individual 
clients. Do they want to learn? What is their level of 
anxiety? What is their level of ability to understand the 
information being presented? Topics for client educa- 
tion in psychiatry include information about medical 
diagnoses, side effects of medications, the importance 
of continuing to take medications, and stress manage- 
ment, among others. Some topics must be individual- 
ized for specific clients, whereas others may be taught 
in group situations. Table 8-2 outlines various topics 
of nursing concern for client education in psychiatry. 

Echternacht (2001) states: 

Milieu therapy interventions are recognized as one 
of the basic-level functions of psychiatric-mental 
health nurses as addressed [in the Psychiatric-Mental 
Health Nursing: Scope and Standards of Practice (ANA, 
2007)]. Milieu therapy has been described as an 
excellent framework for operationalizing [Hildegard] 
Peplau's interpretation and extension of Harry Stack 
Sullivan's Interpersonal Theory for use in nursing 
practice (p. 39). 

■ ABLE 8-2 

The Therapeutic Milieu — 
Topics for Client Education 

1 . Ways to increase self-esteem 

2. Ways to deal with anger appropriately 

3 . Stress-management techniques 

4. How to recognize signs of increasing anxiety and intervene 
to stop progression 

5. Normal stages of grieving and behaviors associated with 
each stage 

6. Assertiveness techniques 

7. Relaxation techniques 

a. Progressive relaxation 

b. Tense and relax 

c. Deep breathing 

d. Autogenics 

8. Medications (specify) 

a. Reason for taking 

b. Harmless side effects 

c. Side effects to report to physician 

d. Importance of taking regularly 

e. Importance of not stopping abruptly 

9. Effects of (substance) on the body 

a. Alcohol 

b. Other depressants 

c. Stimulants 

d. Hallucinogens 

e. Narcotics 

f. Cannabinols 

10. Problem-solving skills 

1 1 . Thought-stopping/thought-switching techniques 

12. Sex education 

a. Structure and function of reproductive system 

b. Contraceptives 

c. Sexually transmitted diseases 

1 3 . Essentials of good nutrition 

14. (For parents/guardians) 

a. Signs and symptoms of substance abuse 

b. Effective parenting techniques 

Now is the time to rekindle interest in the thera- 
peutic milieu concept and to reclaim nursing's tradi- 
tional milieu intervention functions. Nurses need to 
identify the number of registered nurses necessary to 
carry out structured and unstructured milieu functions 
consistent with their Standards of Practice, (p. 43) 


In psychiatry, milieu therapy (or a therapeutic com- 
munity) constitutes a manipulation of the environ- 
ment in an effort to create behavioral changes and to 
improve the psychological health and functioning of 
the individual. 

The goal of therapeutic community is for the client 
to learn adaptive coping, interaction, and relationship 

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skills that can be generalized to other aspects of his or 
her life. 

The community environment itself serves as the 
primary tool of therapy 

I According to Skinner (1979), a therapeutic commu- 
nity is based on seven basic assumptions: 
O The health in each individual is to be realized 

and encouraged to grow. 
O Every interaction is an opportunity for therapeu- 
tic intervention. 
O The client owns his or her own environment. 
O Each client owns his or her behavior. 
O Peer pressure is a useful and a powerful tool. 
O Inappropriate behaviors are dealt with as they 

O Restrictions and punishment are to be avoided. 
Because the goals of milieu therapy relate to helping 
the client learn to generalize that which is learned 
to other aspects of his or her life, the conditions that 
promote a therapeutic community in the psychiatric 
setting are similar to the types of conditions that ex- 
ist in real-life situations. 

I Conditions that promote a therapeutic community 
include the following: 

O The fulfillment of basic physiological needs 
O Physical facilities that are conducive to achieve- 
ment of the goals of therapy 
O The existence of a democratic form of self- 
O The assignment of responsibilities according to 
client capabilities 

O A structured program of social and work-related 

O The inclusion of community and family in the 
program of therapy in an effort to facilitate dis- 
charge from treatment 
The program of therapy on the milieu unit is conduct- 
ed by the interdisciplinary treatment (IDT) team. 
The team includes some, or all, of the following dis- 
ciplines and may include others that are not specified 
here: psychiatrist, clinical psychologist, psychiatric 
clinical nurse specialist, psychiatric nurse, mental 
health technician, psychiatric social worker, occu- 
pational therapist, recreational therapist, art thera- 
pist, music therapist, psycho dramatist, dietitian, and 

Nurses play a crucial role in the management of a 
therapeutic milieu. They are involved in the assess- 
ment, diagnosis, outcome identification, planning, 
implementation, and evaluation of all treatment 

Nurses have significant input into the IDT plans, 
which are developed for all clients. They are respon- 
sible for ensuring that clients' basic needs are ful- 
filled; assessing physical and psychosocial status; ad- 
ministering medication; helping the client develop 
trusting relationships; setting limits on unacceptable 
behaviors; educating clients; and ultimately, helping 
clients, within the limits of their capability, to be- 
come productive members of society. 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 

1. Which of the following are basic assumptions of milieu therapy? Select all that apply. 

a. The client owns his or her own environment. 

b. Each client owns his or her behavior. 

c. Peer pressure is a useful and powerful tool. 

d. Inappropriate behaviors are punished immediately. 

2. John tells the nurse, "I think lights out at 10 o'clock on a weekend is stupid. We should be able to 
watch TV until midnight!" Which of the following is the most appropriate response from the nurse 
on the milieu unit? 

a. "John, you were told the rules when you were admitted." 

b. "You may bring it up before the others at the community meeting, John." 

c. "Some people want to go to bed early, John." 

d. "You are not the only person on this unit, John. You must think of the others." 

3 . In prioritizing care within the therapeutic environment, which of the following nursing 
interventions would receive the highest priority? 

a. Ensuring that the physical facilities are conducive to achievement of the goals of therapy 

b. Scheduling a community meeting for 8:30 each morning 

c. Attending to the nutritional and comfort needs of all clients 

d. Establishing contacts with community resources 

4. In the community meeting, which of the following actions is most important for reinforcing the 
democratic posture of the therapy setting? 

a. Allowing each person a specific and equal amount of time to talk 

b. Reviewing group rules and behavioral limits that apply to all clients 

c. Reading the minutes from yesterday's meeting 

d. Waiting until all clients are present before initiating the meeting 

5. One of the goals of therapeutic community is for clients to become more independent and accept 
self-responsibility. Which of the following approaches by staff best encourages fulfillment of this 

a. Including client input and decisions into the treatment plan 

b. Insisting that each client take a turn as "president" of the community meeting 

c. Making decisions for the client regarding plans for treatment 

d. Requiring that the client be bathed, dressed, and attend breakfast on time each morning 

6. Client teaching is an important nursing function in milieu therapy. Which of the following 
statements by the client indicates the need for knowledge and a readiness to learn? 

a. "Get away from me with that medicine! I'm not sick!" 

b. "I don't need psychiatric treatment. It's my migraine headaches that I need help with." 

c. "I've taken Valium every day of my life for the last 20 years. I'll stop when I'm good and ready!" 

d. "The doctor says I have bipolar disorder. What does that really mean?" 

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7. Which of the following activities would be a responsibility of the clinical psychologist member 
the IDT? 

a. Locates halfway house and arranges living conditions for client being discharged from the 

b. Manages the therapeutic milieu on a 24-hour basis 

c. Administers and evaluates psychological tests that assist in diagnosis 

d. Conducts psychotherapy and administers electroconvulsive therapy treatments 

8. Which of the following activities would be a responsibility of the psychiatric clinical nurse 

a. Manages the therapeutic milieu on a 24-hour basis 

b. Conducts group therapies and provides consultation and education to staff nurses 

c. Directs a group of clients in acting out a situation that is otherwise too painful for a client to 
discuss openly 

d. Locates a halfway house and arranges living conditions for client being discharged from the 

9. On the milieu unit, duties of the staff psychiatric nurse include which of the following? Select all 
that apply. 

a. Medication administration 

b. Client teaching 

c. Medical diagnosis 

d. Reality orientation 

e. Relationship development 

f. Group therapy 

10. Sally was sexually abused as a child. She is a client on the milieu unit with a diagnosis of 
Borderline Personality Disorder. She has refused to talk to anyone. Which of the following 
therapies might the IDT team choose for Sally? Select all that apply. 

a. Music therapy 

b. Art therapy 

c. Psychodrama 

d. Electroconvulsive therapy 


American Nurses Association (ANA). (2007). Psychiatric-mental 
health nursing: Scope and standards of practice. Silver Spring, 

Bowler, J. B. (1991). Transformation into a healing healthcare 
environment: Recovering the possibilities of psychiatric/mental 
health nursing. Perspectives in Psychiatric Care, 27(2), 21-25. 

DeSocio, J., Bowllan, N, & Staschak, S. (1997). Lessons learned in 
creating a safe and therapeutic milieu for children, adolescents, 
and families: Developmental considerations. Journal of Child and 
Adolescent Psychiatric Nursing, 10(^), 18-26. 

Echternacht, M.R. (2001). Fluid group: Concept and clinical 
application in the therapeutic milieu. Journal of the American 
Psychiatric Nurses Association, 7(2), 39-44. 

Hall, B.A (1995). Use of milieu therapy: The context and envi- 
ronment as therapeutic practice for psychiatric-mental health 
nurses. In C.A.Anderson (Ed.), Psychiatric nursing 1974 to 1994: 
A report on the state of the art. St. Louis, MO: Mosby-Year Book. 

Whall, A.L. (1991). Using the environment to improve the mental 
health of the elderly. Journal of 'Gerontological Nursing, 17(7), 39. 


Maslow, A. (1968). Towards a psychology of being (2nd ed.). New York: 
D. Van Nostrand. 

Skinner, K. (1979, August). The therapeutic milieu: Making it work. 

Journal of Psychiatric Nursing and Mental Health Services, 17(H), 

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H A P T E R 

Intervention in Groups 

























psycho drama 

group therapy 

family therapy 


therapeutic group 





After reading this chapter, the student will be able to: 

1. Define a group. 

2. Discuss eight functions of a group. 

3. Identify various types of groups. 

4. Describe physical conditions that influ- 
ence groups. 

5. Discuss "curative factors" that occur in 

6. Describe the phases of group development. 

7. Identify various leadership styles in 

8. Identify various roles that members as- 
sume within a group. 

9. Discuss psychodrama and family thera- 
py as specialized forms of group therapy. 

10. Describe the role of the nurse in group 


Please read the chapter and answer the following questions. 

1. What is the difference between therapeu- 
tic groups and group therapy? 

2. What are the expectations of the leader in 
the initial or orientation phase of group 

3. How does an autocratic leadership style 
affect member enthusiasm and morale? 

4. What is the major goal of family therapy? 


2338_Ch09_167-179.indd 167 

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Human beings are complex creatures who share their 
activities of daily living with various groups of people. 
Sampson and Marthas (1990) have stated: 

We are biological organisms possessing qualities 
shared with all living systems and with others of our 
species. We axe psychological beings with distinctly 
human capabilities for thought, feeling, and action. 
We are also social beings, who function as part of the 
complex webs that link us with other people, (p. 3) 

Health-care professionals not only share their per- 
sonal lives with groups of people but also encounter 
multiple group situations in their professional opera- 
tions. Team conferences, committee meetings, grand 
rounds, and in-service sessions are but a few. In psy- 
chiatry, work with clients and families often takes the 
form of groups. With group work, not only does the 
nurse have the opportunity to reach out to a greater 
number of people at one time, but those individuals 
also assist each other by bringing to the group and 
sharing their feelings, opinions, ideas, and behaviors. 
Clients learn from each other in a group setting. 

This chapter explores various types and methods of 
therapeutic groups that can be used with psychiatric cli- 
ents and the role of the nurse in group intervention. 


Sampson and Marthas (1990) outlined eight functions 
that groups serve for their members. They contend 
that groups may serve more than one function and 
usually serve different functions for different members 
of the group. The eight functions are as follows: 

1. Socialization: The cultural group into which we 
are born begins the process of teaching social 



A collection of individuals whose association is 
founded on shared commonalities of interest val- 
ues, norms, or purpose. Membership in a group 
is generally by chance (born into the group), by 
choice (voluntary affiliation), or by circumstance 
(the result of life-cycle events over which an indi- 
vidual may or may not have control). 

norms. This is continued throughout our lives by 
members of other groups with which we become 

2 . Support: One's fellow group members are available 
in time of need. Individuals derive a feeling of secu- 
rity from group involvement. 

3 . Task completion: Group members provide assist- 
ance in endeavors that are beyond the capacity of 
one individual alone or when results can be achieved 
more effectively as a team. 

4. Camaraderie: Members of a group provide the joy 
and pleasure that individuals seek from interactions 
with significant others. 

5. Informational: Learning takes place within groups. 
Knowledge is gained when individual members 
learn how others in the group have resolved situa- 
tions similar to those with which they are currently 

6. Normative: This function relates to the ways in 
which groups enforce the established norms. 

7. Empowerment: Groups help to bring about im- 
provement in existing conditions by providing sup- 
port to individual members who seek to bring about 
change. Groups have power that individuals alone 
do not. 

8. Governance: An example of the governing function 
is that of rules being made by committees within a 
larger organization. 


The functions of a group vary depending on the rea- 
son the group was formed. Clark (2003) identifies 
three types of groups in which nurses most often par- 
ticipate: task, teaching, and supportive/therapeutic 

Task Groups 

The function of a task group is to accomplish a 
specific outcome or task. The focus is on solving 
problems and making decisions to achieve this out- 
come. Often a deadline is placed on completion of 
the task, and such importance is placed on a satis- 
factory outcome that conflict in the group may be 
smoothed over or ignored in order to focus on the 
priority at hand. 

Teaching Groups 

Teaching, or educational, groups exist to convey 
knowledge and information to a number of indi- 
viduals. Nurses can be involved in teaching groups 
of many varieties, such as medication education, 

2338_Ch09_167-179.indd 168 

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Group Therapy 

A form of psychosocial treatment in which a 
number of clients meet together with a therapist 
for purposes of sharing, gaining personal insight, 
and improving interpersonal coping strategies. 

childbirth education, breast self-examination, and 
effective parenting classes. These groups usually have 
a set time frame or a set number of meetings. Mem- 
bers learn from each other as well as from the des- 
ignated instructor. The objective of teaching groups 
is verbalization or demonstration by the learner of 
the material presented by the end of the designated 

Supportive/Therapeutic Groups 

The primary concern of support groups is to prevent 
future upsets by teaching participants effective ways of 
dealing with emotional stress arising from situational 
or developmental crises. 

For the purposes of this text, it is important to dif- 
ferentiate between therapeutic groups and group 
therapy. Leaders of group therapy generally have ad- 
vanced degrees in psychology, social work, nursing, 
or medicine. They often have additional training or 
experience under the supervision of an accomplished 
professional in conducting group psychotherapy based 
on various theoretical frameworks such as psychoana- 
lytic, psychodynamic, interpersonal, or family dynam- 
ics. Approaches based on these theories are used by the 
group therapy leaders to encourage improvement in 
the ability of group members to function on an inter- 
personal level. 

Therapeutic groups, on the other hand, are based 
to a lesser degree in theory. Focus is more on group 
relations, interactions among group members, and the 
consideration of a selected issue. Like group thera- 
pists, individuals who lead therapeutic groups must 
be knowledgeable in group process-, that is, the way in 
which group members interact with each other. Inter- 
ruptions, silences, judgments, glares, and scapegoating 
are examples of group processes (Clark, 2003). They 
must also have thorough knowledge of group content, 
the topic or issue being discussed within the group, 
and the ability to present the topic in language that 
can be understood by all group members. Many nurses 
who work in psychiatry lead supportive/therapeutic 

Self-Help Groups 

An additional type of group, in which nurses may or may 
not be involved, is the self-help group. Self-help groups 
have grown in numbers and in credibility in recent years. 
They allow clients to talk about their fears and relieve 
feelings of isolation, while receiving comfort and advice 
from others undergoing similar experiences. Examples 
of self-help groups are Alzheimer's Disease and Related 
Disorders, Anorexia Nervosa and Associated Disorders, 
Weight Watchers, Alcoholics Anonymous, Reach to Re- 
covery, Parents Without Partners, Overeaters Anony- 
mous, Adult Children of Alcoholics, and many others re- 
lated to specific needs or illnesses. These groups may or 
may not have a professional leader or consultant. They 
are run by the members, and leadership often rotates 
from member to member. 

Nurses may become involved with self-help groups 
either voluntarily or because their advice or participa- 
tion has been requested by the members. The nurse 
may function as a referral agent, resource person, 
member of an advisory board, or leader of the group. 
Self-help groups are a valuable source of referral for 
clients with specific problems. However, nurses must 
be knowledgeable about the purposes of the group, 
membership, leadership, benefits, and problems that 
might threaten the success of the group before making 
referrals to their clients for a specific self-help group. 
The nurse may find it necessary to attend several 
meetings of a particular group, if possible, to assess its 
effectiveness of purpose and appropriateness for client 



The physical conditions for the group should be set 
up so that there is no barrier between the members. 
For example, a circle of chairs is better than chairs set 
around a table. Members should be encouraged to sit 
in different chairs each meeting. This openness and 
change creates an uncomfortableness that encourages 
anxious and unsettled behaviors that can then be ex- 
plored within the group. 


Various authors have suggested different ranges of size 
as ideal for group interaction: 5 to 10 (Yalom & Leszcz, 
2005), 2 to 15 (Sampson & Marthas, 1990), and 4 to 12 
(Clark, 2003). Group size does make a difference in the 

2338_Ch09_167-179.indd 16 

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interaction among members. The larger the group, the 
less time is available to devote to individual members. 
In fact, in larger groups, those more aggressive individ- 
uals are most likely to be heard, whereas quieter mem- 
bers may be left out of the discussions altogether. On 
the other hand, larger groups provide more opportuni- 
ties for individuals to learn from other members. The 
wider range of life experiences and knowledge provides 
a greater potential for effective group problem-solving. 
Studies have indicated that a composition of seven or 
eight members provides a favorable climate for optimal 
group interaction and relationship development. 


Whether the group is open- or closed-ended is an- 
other condition that influences the dynamics of group 
process. Open-ended groups are those in which mem- 
bers leave and others join at any time while the group 
is active. The continuous movement of members in 
and out of the group creates the type of discomfort 
described previously that encourages unsettled be- 
haviors in individual members and fosters the explo- 
ration of feelings. These are the most common types 
of groups held on short-term inpatient units, although 
they are used in outpatient and long-term care facili- 
ties as well. Closed-ended groups usually have a pre- 
determined, fixed time frame. All members join at the 
time the group is organized and terminate at the end 
of the designated time period. Closed- ended groups 
are often composed of individuals with common issues 
or problems they wish to address. 


Why are therapeutic groups helpful? Yalom & Leszcz 
(2005) describe 1 1 curative factors that individuals can 
achieve through interpersonal interactions within the 
group, some of which are present in most groups in 
varying degrees: 

1 . Instillation of hope: By observing the progress of 
others in the group with similar problems, a group 
member garners hope that his or her problems can 
also be resolved. 

2 . Universality: Individuals come to realize that they 
are not alone in the problems, thoughts, and feel- 
ings they are experiencing. Anxiety is relieved by 
the support and understanding of others in the 
group who share similar (universal) experiences. 

3 . Imparting of information: Knowledge is gained 
through formal instruction as well as the sharing of 
advice and suggestions among group members. 

4. Altruism: Altruism is assimilated by group mem- 
bers through mutual sharing and concern for each 
other. Providing assistance and support to others 
creates a positive self-image and promotes self- 

5. Corrective recapitulation of the primary fam- 
ily group: Group members are able to reexperi- 
ence early family conflicts that remain unresolved. 
Attempts at resolution are promoted through 
feedback and exploration. 

6 . Development of socializing techniques : Through 
interaction with and feedback from other members 
within the group, individuals are able to correct 
maladaptive social behaviors and learn and develop 
new social skills. 

7. Imitative behavior: In this setting, one who has 
mastered a particular psychosocial skill or devel- 
opmental task can be a valuable role model for 
others. Individuals may imitate selected behaviors 
that they wish to develop in themselves. 

8. Interpersonal learning: The group offers many 
and varied opportunities for interacting with other 
people. Insight is gained regarding how one per- 
ceives and is being perceived by others. 

9. Group cohesiveness: Members develop a sense of 
belonging that separates the individual ("I am") from 
the group ("we are"). Out of this alliance emerges a 
common feeling that both individual members and 
the total group are of value to each other. 

10. Catharsis: Within the group, members are able 
to express both positive and negative feelings — 
perhaps feelings that have never been expressed 
before — in a nonthreatening atmosphere. This 
catharsis, or open expression of feelings, is ben- 
eficial for the individual within the group. 

1 1 . Existential factors: The group is able to help in- 
dividual members take direction of their own lives 
and to accept responsibility for the quality of their 

It may be helpful for a group leader to explain these 
curative factors to members of the group. Positive re- 
sponses are experienced by individuals who understand 
and are able to recognize curative factors as they occur 
within the group. 


Groups, like individuals, move through phases of life- 
cycle development. Ideally, groups will progress from 
the phase of infancy to advanced maturity in an effort 
to fulfill the objectives set forth by the membership. 

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Unfortunately, as with individuals, some groups be- 
come fixed in early developmental levels and never 
progress, or experience periods of regression in the 
developmental process. Three phases of group devel- 
opment are discussed here. 

Phase I. Initial or Orientation Phase 
Group Activities 

Leader and members work together to establish the 
rules that will govern the group (e.g., when and where 
meetings will occur, the importance of confidentiality, 
how meetings will be structured). Goals of the group 
are established. Members are introduced to each other. 

Leader Expectations 

The leader is expected to orient members to specific 
group processes, encourage members to participate 
without disclosing too much too soon, promote an en- 
vironment of trust, and ensure that rules established by 
the group do not interfere with fulfillment of the goals. 

Member Behaviors 

In phase I, members have not yet established trust and 
will respond to this lack of trust by being overly polite. 
There is a fear of not being accepted by the group. 
They may try to "get on the good side" of the leader 
with compliments and conforming behaviors. A power 
struggle may ensue as members compete for their po- 
sition in the "pecking order" of the group. 

Phase II. Middle or Working Phase 
Group Activities 

Ideally, during the working phase, cohesiveness has 
been established within the group. This is when the 
productive work toward completion of the task is un- 
dertaken. Problem-solving and decision making occur 
within the group. In the mature group, cooperation 
prevails, and differences and disagreements are con- 
fronted and resolved. 

Leader Expectations 

The role of leader diminishes and becomes more one 
of facilitator during the working phase. Some leader- 
ship functions are shared by certain members of the 
group as they progress toward resolution. The leader 
helps to resolve conflict and continues to foster cohe- 
siveness among the members while ensuring that they 

do not deviate from the intended task or purpose for 
which the group was organized. 

Member Behaviors 

At this point trust has been established among the mem- 
bers. They turn more often to each other and less often 
to the leader for guidance. They accept criticism from 
each other, using it in a constructive manner to create 
change. Occasionally, subgroups will form in which two 
or more members conspire with each other to the exclu- 
sion of the rest of the group. To maintain group cohe- 
sion, these subgroups must be confronted and discussed 
by the entire membership. Conflict is managed by the 
group with minimal assistance from the leader. 

Phase III. Final or Termination Phase 
Group Activities 

The longer a group has been in existence, the more 
difficult termination is likely to be for the members. 
Termination should be mentioned from the outset of 
group formation. It should be discussed in depth for 
several meetings prior to the final session. A sense of 
loss that precipitates the grief process may be in evi- 
dence, particularly in groups that have been successful 
in their stated purpose. 

Leader Expectations 

In the termination phase, the leader encourages the 
group members to reminisce about what has occurred 
within the group, to review the goals and discuss the 
actual outcomes, and to encourage members to pro- 
vide feedback to each other about individual progress 
within the group. The leader encourages members to 
discuss feelings of loss associated with termination of 
the group. 

Member Behaviors 

Members may express surprise over the actual ma- 
terialization of the end. This represents the grief re- 
sponse of denial, which may then progress to anger. 
Anger toward other group members or toward the 
leader may reflect feelings of abandonment (Samp- 
son & Marthas, 1990). These feelings may lead to in- 
dividual members' discussions of previous losses for 
which similar emotions were experienced. Successful 
termination of the group may help members develop 
the skills needed when losses occur in other dimen- 
sions of their lives. 

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Lippitt and White (1958) identified three of the most 
common group leadership styles: autocratic, demo- 
cratic, and laissez-faire. Table 9-1 shows an outline of 
various similarities and differences among the three 
leadership styles. 


Autocratic leaders have personal goals for the group. 
They withhold information from group members, 
particularly issues that may interfere with achieve- 
ment of their own objectives. The message that is 
conveyed to the group is: "We will do it my way. My 
way is best." The focus in this style of leadership is 
on the leader. Members are dependent on the leader 
for problem-solving, decision making, and permission 
to perform. The approach of the autocratic leader is 
one of persuasion, striving to persuade others in the 
group that his or her ideas and methods are superior. 
Productivity is high with this type of leadership, but 
often morale within the group is low because of lack 
of member input and creativity. 


The democratic leadership style focuses on the mem- 
bers of the group. Information is shared with mem- 
bers in an effort to allow them to make decisions re- 
garding achieving the goals for the group. Members 
are encouraged to participate fully in problem-solving 
of issues that relate to the group, including taking ac- 
tion to effect change. The message that is conveyed to 
the group is: "Decide what must be done, consider the 
alternatives, make a selection, and proceed with the 

actions required to complete the task." The leader pro- 
vides guidance and expertise as needed. Productivity 
is lower than it is with autocratic leadership, but mo- 
rale is much higher because of the extent of input al- 
lowed by all members of the group and the potential for 
individual creativity. 


This leadership style allows people to do as they 
please. There is no direction from the leader. In fact, 
the laissez-faire leader's approach is noninvolvement. 
Goals for the group are undefined. No decisions are 
made, no problems are solved, and no action is taken. 
Members become frustrated and confused, and pro- 
ductivity and morale are low. 


Benne and Sheats (1948) identified three major types 
of roles that individuals play within the membership of 
the group. These are roles that serve to: 

1 . Complete the task of the group 

2 . Maintain or enhance group processes 

3 . Fulfill personal or individual needs 

Task roles and maintenance roles contribute to the 
success or effectiveness of the group. Personal roles 
satisfy needs of the individual members, sometimes to 
the extent of interfering with the effectiveness of the 

Table 9-2 presents an outline of specific roles within 
these three major types and the behaviors associated 
with each. 

Leadership Styles— Similarities and Differences 





1. Focus 




2. Task strategy 

Members are persuaded to 
adopt leader ideas 

Members engage in group 

No defined strategy exists 

3 . Member participation 




4. Individual creativity 



Not addressed 

5. Member enthusiasm and 





6. Group cohesiveness 




7. Productivity 


High (may not be as high as 


8. Individual motivation and 

Low (tend 
leader is 
them to 

to work only when 
present to urge 
do so) 

High (satisfaction derived 
from personal input and 

Low (feelings of frustration 
from lack of direction or 

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Table 9- 

Member Roles Within Groups 



Clarifies ideas and suggestions that have been made within the group; brings relationships together 

to pursue common goals 
Examines group plans and performance, measuring against group standards and goals 
Explains and expands upon group plans and ideas 
Encourages and motivates group to perform at its maximum potential 
Outlines the task at hand for the group and proposes methods for solution 
Maintains direction within the group 

Relieves conflict within the group by assisting members to reach a compromise agreeable to all 

Offers recognition and acceptance of others' ideas and contributions 

Listens attentively to group interaction; is passive participant 

Encourages acceptance of and participation by all members of the group 

Minimizes tension within the group by intervening when disagreements produce conflict 

Expresses negativism and hostility toward other members; may use sarcasm in effort to degrade the 
status of others 

Resists group efforts; demonstrates rigid and sometimes irrational behaviors that impede group 

Manipulates others to gain control; behaves in authoritarian manner 

Uses the group to gain sympathy from others; seeks to increase self- confidence from group feed- 
back; lacks concern for others or for the group as a whole 

Maintains control of the group by dominating the conversation 

Does not participate verbally; remains silent for a variety of reasons — may feel uncomfortable with 
self-disclosure or may be seeking attention through silence 

Talks about personal accomplishments in an effort to gain attention for self 

Shares intimate details about self with group; is the least reluctant of the group to do so; may 
frighten others in the group and inhibit group progress with excessive premature self-disclosure 

Source: Adapted from Benne and Sheats (1948). 

Task Roles 







Maintenance Roles 






Individual (Personal) Roles 





Mute or silent member 

Recognition seeker 


A specialized type of therapeutic group, called psych- 
odrama, was introduced by J. L. Moreno, a Viennese 
psychiatrist. Moreno's method employs a dramatic ap- 
proach in which clients become "actors" in life-situation 

The group leader is called the director, group members 
are the audience, and the set, or stage, may be specially de- 
signed or may just be any room or part of a room selected 
for this purpose. Actors are members from the audience 
who agree to take part in the "drama" by role-playing a 
situation about which they have been informed by the 
director. Usually the situation is an issue with which one 
individual client has been struggling. The client plays the 
role of himself or herself and is called the protagonist. In 
this role, the client is able to express true feelings toward 
individuals (represented by group members) with whom 
he or she has unresolved conflicts. 

In some instances, the group leader may ask for a cli- 
ent to volunteer to be the protagonist for that session. 
The client may chose a situation he or she wishes to 
enact and select the audience members to portray the 
roles of others in the life situation. The psychodrama 
setting provides the client with a safer and less threat- 
ening atmosphere than the real situation in which to 
express true feelings. Resolution of interpersonal con- 
flicts is facilitated. 

When the drama has been completed, group mem- 
bers from the audience discuss the situation they have 
observed, offer feedback, express their feelings, and 
relate their own similar experiences. In this way, all 
group members benefit from the session, either di- 
rectly or indirectly. 

Nurses often serve as actors, or role players, in 
psychodrama sessions. Leaders of psychodrama have 
graduate degrees in psychology, social work, nurs- 
ing, or medicine, with additional training in group 

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therapy and specialty preparation to become a psy- 


In family therapy, the family is viewed as a system in 
which the members are interdependent; a change in 
one part (member) within the system affects or creates 
change in all the other parts (members). The focus is 
not on an individual, identified client; it is on the fam- 
ily as a whole. The basic concept of this form of treat- 
ment is that it is faster, more logical, more satisfactory, 
and more economical to treat all members of a system 
of relationships than to concentrate on the person who 
is supposed to be in need of treatment (Goldenberg, 
Goldenberg, & Pelavin, 2011). 

Because the major goal of family therapy is to bring 
about positive change in relationships, the therapist 
ideally conducts the initial assessment with the entire 
family. If this is not possible, information is gathered 
from the client who has sought treatment and an ap- 
pointment is scheduled to meet with the family at a 
later date. The initial assessment is not complete until 
the therapist has had the opportunity to observe the 
interactions among all family members. 

Some family therapists favor the use of a genogram 
in the study of multiple generations within families. 
Genograms offer the convenience of a great deal of 
information in a small amount of space. They can also 
be used as teaching tools with the family itself. An 
overall picture of the life of the family over several 
generations can be conveyed, including roles that 
various family members play and emotional distance 



A group of individuals who are bound by strong 
emotional ties, a sense of belonging, and a passion 
for being involved in one another's lives (Wright, 
Watson, & Bell, 1996). 

Family Therapy 

A type of therapeutic modality in which the focus 
of treatment is on the family as a unit. It represents 
a form of intervention in which members of a fam- 
ily are assisted to identify and change problematic, 
maladaptive, self-defeating, repetitive relationship 
patterns (Goldenberg, Goldenberg, & Pelavin, 2011). 

between specific individuals. Areas for change can be 
easily identified. A sample genogram is presented in 
Figure 9-1. 

Once the assessment has been completed and prob- 
lems identified, family members establish goals for 
change with guidance from the therapist. Change oc- 
curs through open, honest communication among all 
family members. The family therapist's role is to fa- 
cilitate this type of interaction. As goals are achieved 
and change occurs, family members will demonstrate 
the ability to communicate effectively, the ability to 
resolve conflicts adaptively, and the ability for each to 
function both independently and interdependently in 
a healthy manner. 

Nurses who conduct family therapy are expected 
to possess a graduate degree and have considerable 
knowledge of family theory. However, it is within the 
realm of the generalist nurse in psychiatry to contrib- 
ute to the assessment and planning phases of family 
therapy and to ongoing observation and evaluation. 
Family consideration in individual client care is also 
essential. Nurses should have a basic understanding 
of family dynamics and the ability to distinguish be- 
tween functional and dysfunctional behaviors within 
a family system. 


Nurses participate in group situations on a daily ba- 
sis. In health-care settings, nurses serve on or lead task 
groups that create policy, describe procedures, and 
plan client care. They are also involved in a variety of 
other groups aimed at the institutional effort of serv- 
ing the consumer. Nurses are encouraged to use the 
steps of the nursing process as a framework for task 
group leadership. 

In psychiatry, nurses may lead various types of ther- 
apeutic groups, such as client education, assertiveness 
training, support, parent, and transition to discharge 
groups, among others. To function effectively in the 
leadership capacity for these groups, nurses need to 
be able to recognize various processes that occur in 
groups (e.g., the phases of group development, the var- 
ious roles that people play within group situations, and 
the motivation behind the behavior). They also need 
to be able to select the most appropriate leadership 
style for the type of group being led. Generalist nurses 
may develop these skills as part of their undergraduate 
education, or they may pursue additional study while 
serving and learning as the co-leader of a group with a 
more experienced nurse leader. 

2338_Ch09_167-179.indd 174 

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I I Male 

Q_J Female 

^^— Married (m) 

# Divorced (d) 

/ Separated (s) 

__ _ Unmarried 

/va>v> Conflictual 

s^r^v relationship 


| Offspring 



A Miscarriage 
or abortion 

ITI Adopted (boy) 


X Death 

NOTE: Include ages and 
dates of significant 
events when known. 

FIGURE 9-1 Sample genogram. CA, cancer; CVA, cerebrovascular accident; MI, myocardial infarction. 

Generalist nurses in psychiatry rarely serve as 
leaders of psychotherapy groups. The Psychiatric- 
Mental Health Nursing Scope and Standards of Practice 
(American Nurses Association, 2007) specifies that 
nurses who serve as group psychotherapists should have 
a minimum of a master's degree in psychiatric nursing. 
Other criteria that have been suggested are educa- 
tional preparation in group theory, extended practice 
as a group co-leader or leader under the supervision 
of an experienced psychotherapist, and participation 
in group therapy on an experiential level. Additional 
specialist training is required beyond the master's level 
to prepare nurses to become family therapists or psy- 
cho dramatists. 

Leading therapeutic groups is within the realm of 
nursing practice. Because group work is such a com- 
mon therapeutic approach in the discipline of psychia- 
try, nurses working in this field must continually strive 
to expand their knowledge and use of group process as 
a significant psychiatric nursing intervention. 


Knowledge of human behavior in general and the 
group process in particular is essential to effective 
group leadership. 


■ A group has been defined as a collection of individu- 
als whose association is founded on shared commo- 
nalities of interest, values, norms, or purpose. 
Eight group functions have been identified: socializa- 
tion, support, task completion, camaraderie, informa- 
tional, normative, empowerment, and governance. 
There are three major types of groups: task groups, 
teaching groups, and supportive/therapeutic groups. 
The function of task groups is to solve problems, 
make decisions, and achieve a specific outcome. 
In teaching groups, knowledge and information are 
conveyed to a number of individuals. 

I The function of supportive/therapeutic groups is 
to educate people to deal effectively with emotional 
stress in their lives. 

In self-help groups, members share the same type of 
problem and help each other to prevent decompen- 
sation as a result of that problem. 
Therapeutic groups differ from group therapy in 
that group therapy is more theory based and the 
leaders generally have advanced degrees in psychol- 
ogy, social work, nursing, or medicine. 
Placement of the seating and size of the group can 
influence group interaction. 

Groups can be open-ended (when members leave 
and others join at any time while the group is active) 

2338_Ch09_167-179.indd 175 

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or closed-ended (when groups have a predetermined, 
fixed time frame and all members join at the same 
time and leave when the group disbands). 
Yalom and Leszcz describe the following curative 
factors that individuals derive from participation 
in therapeutic groups: the instillation of hope, uni- 
versality, the imparting of information, altruism, 
the corrective recapitulation of the primary family 
group, the development of socializing techniques, 
imitative behavior, interpersonal learning, group 
cohesiveness, catharsis, and existential factors. 
Groups progress through three phases: the initial 
(orientation) phase, the working phase, and the ter- 
mination phase. 

Group leadership styles include autocratic, demo- 
cratic, and laissez-faire. 

Members play various roles within groups. These 
roles are categorized according to task roles, main- 
tenance roles, and personal roles. 
Psychodrama is a specialized type of group therapy 
that uses a dramatic approach in which clients be- 
come "actors" in life-situation scenarios. 

The psychodrama setting provides the client with a 
safer and less threatening atmosphere than the real 
situation in which to express and work through un- 
resolved conflicts. 

Family therapy brings together some or all members 
of the family in a group situation. The major goal is 
to bring about positive change in relationships. 
The family therapist helps family members to iden- 
tify problems, establish goals for change, and work 
toward achievement of those goals through open, 
honest communication. 

Nurses lead various types of therapeutic groups in 
the psychiatric setting. Knowledge of human behav- 
ior in general and the group process in particular is 
essential to effective group leadership. 
Specialized training, in addition to a master's degree, 
is required for nurses to serve as group psychothera- 
pists, psycho dramatists, or family therapists. 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 


1 . NJ is the nurse leader of a childbirth preparation group. Each week she shows various films and 
sets out various reading materials. She expects the participants to utilize their time on a topic of 
their choice or practice skills they have observed on the films. Two couples have dropped out of 
the group, stating, "This is a big waste of time." Which type of group and style of leadership is 
described in this situation? 

a. Task/democratic 

b. Teaching/laissez-faire 

c. Self-help/democratic 

d. Supportive-therapeutic/autocratic 

2 . MK is a psychiatric nurse who has been selected to lead a group for women who desire to lose 
weight. The criterion for membership is that they must be at least 20 pounds overweight. All have 
tried to lose weight on their own many times in the past without success. At their first meeting, MK 
provides suggestions as the members determine what their goals will be and how they plan to go 
about achieving those goals. They decided how often they wanted to meet and what they planned 
to do at each meeting. Which type of group and style of leadership is described in this situation? 

a. Task/autocratic 

b. Teaching/democratic 

c. Self-help/laissez-faire 

d. Supportive-therapeutic/democratic 

3 . JJ is a staff nurse on a surgical unit. He has been selected as leader of a newly established group of 
staff nurses organized to determine ways to decrease the number of medication errors occurring 
on the unit. JJ has definite ideas about how to bring this about. He has also applied for the position 
of Head Nurse on the unit and believes that if he is successful in leading the group toward 
achievement of its goals, he can also facilitate his chances for promotion. At each meeting he 
addresses the group in an effort to convince the members to adopt his ideas. Which type of group 
and style of leadership is described in this situation? 

a. Task/autocratic 

b. Teaching/autocratic 

c. Self-help/democratic 

d. Supportive-therapeutic/laissez-faire 

4. The nurse leader is explaining about group "curative factors" to members of the group. She tells 
the group that group situations are beneficial because members can see that they are not alone in 
their experiences. This is an example of which curative factor? 

a. Altruism 

b. Imitative behavior 

c. Universality 

d. Imparting of information 

5. Nurse Jones is the leader of a bereavement group for widows. Nancy is a new member. She listens 
to the group and sees that Jane has been a widow for 5 years now. Jane has adjusted well, and 
Nancy thinks maybe she can too. This is an example of which curative factor? 

a. Universality 

b. Imitative behavior 

c. Instillation of hope 

d. Imparting of information 

2338_Ch09_167-179.indd 177 

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6. Paul is a member of an anger management group. He knew that people did not want to be his 
friend because of his violent temper. In the group, he has learned to control his temper and form 
satisfactory interpersonal relationships with others. This is an example of which curative factor? 

a. Catharsis 

b. Altruism 

c. Imparting of information 

d. Development of socializing techniques 

7. Henry is a member of an Alcoholics Anonymous group. He learned about the effects of alcohol on 
the body when a nurse from the chemical dependency unit spoke to the group. This is an example 
of which curative factor? 

a. Catharsis 

b. Altruism 

c. Imparting of information 

d. Universality 

8. Sandra is the nurse leader of a supportive-therapeutic group for individuals with anxiety disorders. 
In this group, Nancy talks incessantly. When someone else tries to make a comment, she refuses 
to allow him or her to speak. What type of member role is Nancy assuming in this group? 

a. Aggressor 

b. Monopolizer 

c. Blocker 

d. Seducer 

9. Sandra is the nurse leader of a supportive-therapeutic group for individuals with anxiety disorders. 
On the first day the group meets, Valerie speaks first and begins by sharing the intimate details of 
her incestuous relationship with her father. What type of member role is Valerie assuming in this 

a. Aggressor 

b. Monopolizer 

c. Blocker 

d. Seducer 

10. Sandra is the nurse leader of a supportive-therapeutic group for individuals with anxiety disorders. 
Violet, who is beautiful but lacks self-confidence, states to the group, "Maybe if I became a blond 
my boyfriend would love me more." Larry responds, "Listen, dummy, you need more than blond 
hair to keep the guy around. A bit more in the brains department would help!" What type of 
member role is Larry assuming in this group? 

a. Aggressor 

b. Monopolizer 

c. Blocker 

d. Seducer 




2338_Ch09_167-179.indd 178 

8/31/10 5:58:32 PM 




American Nurses Association (ANA). (2007). Psychiatric-; 

health nursing: Scope and standards of practice. Silver Spring, 

Clark, C.C. (2003). Group leadership skills (4th ed.). New York: 

Goldenberg, I., Goldenberg, H., & Pelavin, E.G. (2011). Family 

therapy. In R.J. Corsini & D. Wedding (Eds.), Current 

psych otherapies (9th ed.). Belmont, CA: Brooks/Cole. 

Sampson, E.E., & Marthas, M. (1990). Group process for the health 
professions (3rd ed.). Albany, NY: Delmar Publishers. 

Wright, L.M., Watson, W.L., & Bell, J.M. (1996). Beliefs: The heart 
of healing in families and illness. New York: Basic Books. 

Yalom, I.D., & Leszcz, M. (2005). The theory and practice of group 
psychotherapy (5th ed.). New York: Basic Books. 


Benne, K.D., & Sheats, P. (1948, Spring). Functional roles of group 
members. Journal of Social Issues, 4(2), 41-49. 

Lippitt, R., & White, R.K. (1958). An experimental study of leader- 
ship and group life. In E.E. Maccoby, T.M. Newcomb, & 

E.L. Hartley (Eds.), Readings in social psychology (3rd ed.). New 
York: Holt, Rinehart, & Winston. 

2338_Ch09_167-179.indd 179 

8/31/10 5:58:35 PM 


H A P T E R 

Intervening in Crises 
















crisis intervention 

prodromal syndrome 




After reading this chapter, the student will be able to: 

1. Define crisis. 

2. Describe four phases in the development 
of a crisis. 

3. Identify types of crises that occur in peo- 
ple's lives. 

4. Discuss the goal of crisis intervention. 

5. Describe the steps in crisis intervention. 

6. Identify the role of the nurse in crisis 

7. Apply the nursing process to clients expe- 
riencing crises. 

8. Apply the nursing process to clients ex- 
pressing anger or aggression. 

9. Apply the nursing process to care of vic- 
tims of disaster. 


Please read the chapter and answer the following questions. 

1. Name the three factors that determine 
whether a person experiences a crisis in 
response to a stressful situation. 

2. What is the goal of crisis intervention? 


3. What symptoms often precede violent 

4. Describe behaviors common to preschool 
children following a traumatic event. 

2338_Ch10_180-203.indd 180 

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Stressful situations are a part of everyday life. Any 
stressful situation can precipitate a crisis. Crises re- 
sult in a disequilibrium from which many individuals 
require assistance to recover. Crisis intervention re- 
quires problem-solving skills that are often diminished 
by the level of anxiety accompanying disequilibrium. 
Assistance with problem-solving during the crisis pe- 
riod preserves self-esteem and promotes growth with 

In recent years, individuals in the United States have 
been faced with a number of catastrophic events, in- 
cluding natural disasters such as tornados, earthquakes, 
hurricanes, and floods. Also, manmade disasters, such 
as the Oklahoma City bombing and the attacks on the 
World Trade Center and the Pentagon, have created 
psychological stress of enormous proportions in popu- 
lations around the world. 

This chapter examines the phases in the develop- 
ment of a crisis and the types of crises that occur in 
people's lives. The methodology of crisis intervention, 
including the role of the nurse, is explored. A discus- 
sion of disaster nursing is also presented. 


A number of characteristics have been identified 
upon which the concept of crisis is based (Aguilera, 
1998; Caplan, 1964; Winston, 2008). They include 
the following: 

1. Crisis occurs in all individuals at one time or an- 
other and is not necessarily equated with psychopa- 

2. Crises are precipitated by specific identifiable 

3 . Crises are personal by nature. What may be consid- 
ered a crisis situation by one individual may not be 
so for another. 

4. Crises are acute, not chronic, and will be resolved in 
one way or another within a brief period. 



A sudden event in one's life that disturbs homeos- 
tasis, during which usual coping mechanisms can- 
not resolve the problem (Lagerquist, 2006). 

5. A crisis situation contains the potential for psycho- 
logical growth or deterioration. 

Individuals who are in crisis feel helpless to change. 
They do not believe they have the resources to deal 
with the precipitating stressor. Levels of anxiety rise to 
the point that the individual becomes nonfunctional, 
thoughts become obsessional, and all behavior is aimed 
at relief of the anxiety being experienced. The feeling 
is overwhelming and may affect the individual physi- 
cally as well as psychologically. 

Bateman and Peternelj -Taylor (1998) state: 

Outside Western culture, a crisis is often viewed as a 
time for movement and growth. The Chinese symbol 
for crisis consists of the characters for danger and 
opportunity [Fig. 10-1]. When a crisis is viewed as 
an opportunity for growth, those involved are much 
more capable of resolving related issues and more 
able to move toward positive changes. When the 
crisis experience is overwhelming because of its scope 
and nature or when there has not been adequate 
preparation for the necessary changes, the dangers 
seem paramount and overshadow any potential 
growth. The results are maladaptive coping and 
dysfunctional behavior, (pp. 144-145) 



The development of a crisis situation follows a rela- 
tively predictable course. Caplan (1964) outlined four 
specific phases through which individuals progress in 
response to a precipitating stressor and that culminate 
in the state of acute crisis. 

Phase 1 : The individual is exposed to a precipitating stres- 
sor. Anxiety increases; previous problem-solving 
techniques are employed. 

Phase 2: When previous problem-solving techniques do 
not relieve the stressor, anxiety increases further. The 
individual begins to feel a great deal of discomfort 


FIGURE 10—1 Chinese symbol for crisis. 

2338_Ch10_180-203.indd 181 

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at this point. Coping techniques that have worked 
in the past are attempted, only to create feelings of 
helplessness when they are not successful. Feelings 
of confusion and disorganization prevail. 

Phase 3: All possible resources, both internal and external, 
are called on to resolve the problem and relieve the dis- 
comfort. The individual may try to view the problem 
from a different perspective, or even to overlook 
certain aspects of it. New problem-solving tech- 
niques may be used, and, if effectual, resolution may 
occur at this phase, with the individual returning to 
a higher, a lower, or the previous level of premorbid 

Phase 4: If resolution does not occur in previous phases, 
Caplan states that "the tension mounts beyond a further 
threshold or its burden increases over time to a break- 
ing point. Major disorganization of the individual with 
drastic results often occurs. " Anxiety may reach panic 
levels. Cognitive functions are disordered, emotions 
are labile, and behavior may reflect the presence of 
psychotic thinking. 

These phases are congruent with the concept of "bal- 
ancing factors" as described by Aguilera (1998). These 
factors affect the way in which an individual perceives 
and responds to a precipitating stressor. A schematic of 
these balancing factors is illustrated in Figure 10-2. 

The paradigm set forth by Aguilera suggests that 
whether an individual experiences a crisis in response 

Precipitating event 

State of disequilibrium 

Balancing factors 

Individual's perception 

of the event 

I I 

Support systems Systems 

I I 

Coping mechanisms 

Problem is resolved 

Problem unresolved 

to a stressful situation depends upon the following 
three factors: 

1 . The individual's perception of the event: If the 

event is perceived realistically, the individual is 
more likely to draw upon adequate resources to re- 
store equilibrium. If the perception of the event is 
distorted, attempts at problem-solving are likely to 
be ineffective, and restoration of equilibrium goes 

2 . The availability of situational supports: Aguilera 
states, "Situational supports are those persons who 
are available in the environment and who can be 
depended on to help solve the problem" (p. 37). 
Without adequate situational supports during a 
stressful situation, an individual is most likely to feel 
overwhelmed and alone. 

3 . The availability of adequate coping mechanisms: 
When a stressful situation occurs, individuals draw 
upon behavioral strategies that have been success- 
ful for them in the past. If these coping strategies 
work, a crisis may be diverted. If not, disequilibrium 
may continue and tension and anxiety increase. 

As previously set forth, it is assumed that crises are 
acute, not chronic, situations that will be resolved in 
one way or another within a brief period. Winston 
(2008) states, "Crises tend to be time limited, gener- 
ally lasting no more than a few months; the duration 
depends on the stressor and on the individual's percep- 
tion of and response to the stressor" (p. 1270). Crises 
can become growth opportunities when individuals 
learn new methods of coping that can be preserved and 
used when similar stressors recur. 


Baldwin (1978) identified six classes of emotional cri- 
ses, which progress by degree of severity. As the meas- 
ure of psychopathology increases, the source of the 
stressor changes from external to internal. The type of 
crisis determines the method of intervention selected. 

Class 1: Dispositional Crises 

Definition. An acute response to an external situ- 
ational stressor. 


FIGURE 10-2 The effects of balancing factors in a stressful 

Nancy and Ted have been married for 3 years and have 
a 1 -year-old daughter. Ted has been having difficulty 
with his boss at work. Twice during the past 6 months 

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he has exploded in anger at home and has become abu- 
sive with Nancy. Last night he became angry that din- 
ner was not ready when he expected. He grabbed the 
baby from Nancy and tossed her, screaming, into her 
crib. He hit and punched Nancy until she feared for 
her life. This morning when he left for work, she took 
the baby and went to the emergency department of the 
city hospital, not having anywhere else to go. 

Intervention. Nancy's physical wounds were cared for 
in the emergency department. The mental health coun- 
selor provided support and guidance in terms of present- 
ing alternatives to her. Needs and issues were clarified, 
and referrals for agency assistance were made. 

Class 2: Crises of Anticipated Life 

Definition. Normal life-cycle transitions that may be 
anticipated over which the individual may feel a lack 
of control. 


College student J.T. is placed on probationary status 
because of low grades this semester. His wife had a 
baby and had to quit her job. He increased his working 
hours from part time to full time to compensate and 
therefore had little time for studies. He presents him- 
self to the student-health nurse practitioner complain- 
ing of numerous vague physical complaints. 

Intervention. Physical examination should be performed 
(physical symptoms could be caused by depression) and 
ventilation of feelings encouraged. Reassurance and sup- 
port should be provided as needed. The client should be 
referred to services that can provide financial and other 
types of needed assistance. Problematic areas should be 
identified and approaches to change discussed. 

Class 3: Crises Resulting from Traumatic 

Definition. Crises precipitated by unexpected exter- 
nal stresses over which the individual has little or no 
control and from which he or she feels emotionally 
overwhelmed and defeated. 


Sally was a waitperson whose shift ended at midnight. 
Two weeks ago, while walking to her car in the de- 
serted parking lot, she was abducted by two men with 
guns, taken to an abandoned building, and raped and 

beaten. Since that time, her physical wounds have 
nearly healed. However, Sally cannot be alone; is con- 
stantly fearful; relives the experience in flashbacks and 
dreams; and is unable to eat, sleep, or work at her job 
in the restaurant. Her friend offers to accompany her 
to the mental health clinic. 

Intervention. The nurse should encourage Sally to 
talk about the experience and to express her feelings 
associated with it. The nurse should offer reassurance 
and support; discuss stages of grief and how rape causes 
a loss of self- worth, triggering the grief response; iden- 
tify support systems that can help Sally to resume her 
normal activities; and explore new methods of coping 
with emotions arising from a situation with which she 
has had no previous experience. 

Class 4: Maturational/Developmental 

Definition. Crises that occur in response to situations 
that trigger emotions related to unresolved conflicts in 
one's life. These crises are of internal origin and reflect 
underlying developmental issues that involve depend- 
ency, value conflicts, sexual identity, control, and ca- 
pacity for emotional intimacy. 


Bob is 40 years old. He has just been passed over for a 
job promotion for the third time. He has moved many 
times within the large company for which he works, 
usually after angering and alienating himself from the 
supervisor. His father was domineering and became abu- 
sive when Bob did not comply with his every command. 
Over the years, Bob's behavioral response became one of 
passive-aggressiveness — first with his father, then with 
his supervisors. This third rejection has created feelings 
of depression and intense anxiety in Bob. At his wife's in- 
sistence, he has sought help at the mental health clinic. 

Intervention. The primary intervention is to help the 
individual identify the unresolved developmental issue 
that is creating the conflict. Support and guidance are of- 
fered during the initial crisis period, and then assistance 
is given to help the individual work through the underly- 
ing conflict in an effort to change response patterns that 
are creating problems in his current life situation. 

Class 5: Crises Reflecting 

Definition. Emotional crises in which preexisting psy- 
chopathology has been instrumental in precipitating the 

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crisis or in which psychopathology significantly impairs 
or complicates adaptive resolution. Examples of psycho- 
pathology that may precipitate crises include borderline 
personality, severe neuroses, characterological disorders, 
or schizophrenia. 


Sonja, age 29, was diagnosed with borderline person- 
ality at age 18. She has been in therapy on a weekly 
basis for 10 years, with several hospitalizations for sui- 
cide attempts during that time. She has had the same 
therapist for the past 6 years. This therapist told Sonja 
today that she is to be married in 1 month and will 
be moving across the country with her new husband. 
Sonja is distraught and experiencing intense feelings 
of abandonment. She is found wandering in and out of 
traffic on a busy expressway, oblivious to her surround- 
ings. Police bring her to the emergency department of 
the hospital. 

Intervention. The initial intervention is to help bring 
down the level of anxiety in Sonja that has created 
feelings of unreality in her. She requires that some- 
one stay with her and reassure her of her safety and 
security. After the feelings of panic anxiety have sub- 
sided, she should be encouraged to verbalize her feel- 
ings of abandonment. Regressive behaviors should be 
discouraged. Positive reinforcement should be given 
for independent activities and accomplishments. The 
primary therapist will need to pursue this issue of ter- 
mination with Sonja at length. Referral to a long-term 
care facility may be required. 

Class 6: Psychiatric Emergencies 

Definition. Crisis situations in which general func- 
tioning has been severely impaired and the individual 
rendered incompetent or unable to assume personal 
responsibility. Examples include acutely suicidal in- 
dividuals, drug overdoses, reactions to hallucinogenic 
drugs, acute psychoses, uncontrollable anger, and alco- 
hol intoxication. 


Jennifer, age 16, had been dating Joe, the star high 
school football player, for 6 months. After the game on 
Friday night, Jennifer and Joe went to Jackie's house, 
where a number of high school students had gathered 
for an after-game party. No adults were present. About 
midnight, Joe told Jennifer that he did not want to date 
her anymore. Jennifer became hysterical, and Jackie 

was frightened by her behavior. She took Jennifer 
to her parent's bedroom and gave her a Valium from 
a bottle in her mother's medicine cabinet. She left 
Jennifer lying on her parent's bed and returned to the 
party downstairs. About an hour later, she returned to 
her parent's bedroom and found that Jennifer had re- 
moved the bottle of Valium from the cabinet and swal- 
lowed all of the tablets. Jennifer was unconscious and 
Jackie could not awaken her. An ambulance was called 
and Jennifer was transported to the local hospital. 

Intervention. The crisis team monitored vital signs, 
ensured maintenance of adequate airway, initiated 
gastric lavage, and administered activated charcoal to 
minimize absorption. Jennifer's parents were notified 
and rushed to the hospital. The situation was explained 
to them, and they were encouraged to stay by her side. 
When the physical crisis was resolved, Jennifer was 
transferred to the psychiatric unit. In therapy, she was 
encouraged to ventilate her feelings regarding the re- 
jection and subsequent overdose. Family therapy ses- 
sions were conducted in an effort to clarify interper- 
sonal issues and to identify areas for change. On an 
individual level, Jennifer's therapist worked with her to 
establish more adaptive methods of coping with stress- 
ful situations. 


Individuals experiencing crises have an urgent need 
for assistance. In crisis intervention, the therapist, or 
other intervener, becomes a part of the individual's life 
situation. Because of the individual's emotional state, 
he or she is unable to problem-solve, so requires guid- 
ance and support from another to help mobilize the 
resources needed to resolve the crisis. 

Lengthy psychological interpretations are not ap- 
propriate for crisis intervention. It is a time for doing 
what is needed to help the individual get relief and for 
calling into action all the people and other resources 
required to do so. Aguilera (1998) states: 

The goal of crisis intervention is the resolution of 
an immediate crisis. Its focus is on the supportive, 
with the restoration of the individual to his precrisis 
level of functioning or possibly to a higher level of 
functioning. The therapist's role is direct, supportive, 
and that of an active participant, (p. 24) 

Crisis intervention takes place in both inpatient and 
outpatient settings. The basic methodology relies heav- 
ily on orderly problem-solving techniques and struc- 
tured activities that are focused on change. Through 
adaptive change, crises are resolved and growth occurs. 

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Because of the time limitation of crisis intervention, 
the individual must experience some degree of relief 
almost from the first interaction. Crisis intervention, 
then, is not aimed at major personality change or re- 
construction (as may be the case in long-term psycho- 
therapy), but rather at using a given crisis situation, at 
the very least, to restore functioning and, at most, to 
enhance personal growth. 


Nurses respond to crisis situations on a daily basis. Cri- 
ses can occur on every unit in the general hospital, in 
the home setting, the community health-care setting, 
schools, offices, and in private practice. Indeed, nurses 
may be called on to function as crisis helpers in virtually 
any setting committed to the practice of nursing. 

Roberts and Ottens (2005) provide a seven-stage 
model of crisis intervention. This model is summarized 
in Table 10-1. Aguilera (1998) describes four specific 
phases in the technique of crisis intervention that are 
clearly comparable to the steps of the nursing process. 
These phases are discussed in the following paragraphs. 

Phase 1. Assessment 

In this phase, the crisis helper gathers information re- 
garding the precipitating stressor and the resulting crisis 
that prompted the individual to seek professional help. 
A nurse in crisis intervention might perform some of 
the following assessments: 

• Ask the individual to describe the event that pre- 
cipitated this crisis. 

• Determine when it occurred. 

• Assess the individual's physical and mental status. 

• Determine if the individual has experienced this 
stressor before. If so, what method of coping was 
used? Have these methods been tried this time? 

• If previous coping methods were tried, what was the 

• If new coping methods were tried, what was the 

• Assess suicide or homicide potential, plan, and 

• Assess the adequacy of support systems. 

• Determine level of precrisis functioning. Assess the 
usual coping methods, available support systems, 
and ability to problem-solve. 

• Assess the individual's perception of personal strengths 
and limitations. 

• Assess the individual's use of substances. 

Information from the comprehensive assessment is 
then analyzed, and appropriate nursing diagnoses re- 
flecting the immediacy of the crisis situation are iden- 
tified. Some nursing diagnoses that may be relevant 

• Ineffective coping 

• Anxiety (severe to panic) 

• Disturbed thought processes 

• Risk for self- or other- directed violence 

• Rape-trauma syndrome 

• Post-trauma syndrome 

• Fear 

Phase 2. Planning of Therapeutic 

In the planning phase of the nursing process, the nurse 
selects the appropriate nursing actions for the identi- 
fied nursing diagnoses. In planning the interventions, 
the type of crisis, as well as the individual's strengths 
and available resources for support, are taken into con- 
sideration. Goals are established for crisis resolution 
and a return to, or increase in, the precrisis level of 

Phase 3. Intervention 

During phase 3, the actions that were identified in 
phase 2 are implemented. The following interventions 
are the focus of nursing in crisis intervention: 

• Use a reality-oriented approach. The focus of the 
problem is on the here and now. 

• Remain with the individual who is experiencing 
panic anxiety. 

• Establish a rapid working relationship by showing 
unconditional acceptance, by active listening, and 
by attending to immediate needs. 

• Discourage lengthy explanations or rationalizations 
of the situation; promote an atmosphere for verbali- 
zation of true feelings. 

• Set firm limits on aggressive, destructive behaviors. 
At high levels of anxiety, behavior is likely to be im- 
pulsive and regressive. Establish at the outset what is 
acceptable and what is not, and maintain consistency. 

• Clarify the problem that the individual is facing. 
The nurse does this by describing his or her per- 
ception of the problem and comparing it with the 
individual's perception of the problem. 

• Help the individual determine what he or she be- 
lieves precipitated the crisis. 

• Acknowledge feelings of anger, guilt, helplessness, 
and powerlessness, while taking care not to provide 
positive feedback for these feelings. 

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Table 10 

Roberts' Seven-Stage Crisis Intervention Model 

Stage Interventions 

Stage I. Psychosocial and lethality as- • Conduct a rapid but thorough biopsychosocial assessment, 

Stage II. Rapidly establish rapport. • The counselor uses genuineness, respect, and unconditional acceptance to establish 

rapport with the client. 
• Skills such as good eye contact, a nonjudgmental attitude, flexibility, and maintaining a 
positive mental attitude are important. 

Stage III. Identify the major problems • Identify the precipitating event that has led the client to seek help at the present time, 
or crisis precipitants. • Identify other situations that led up to the precipitating event. 

• Prioritize major problems with which the client needs help. 

• Discuss client's current style of coping, and offer assistance in areas where modification 
would be helpful in resolving the present crisis and preventing future crises. 

Stage IV. Deal with feelings and emo- • Encourage the client to vent feelings. Provide validation. 

tions. • Use therapeutic communication techniques to help the client explain his or her story 

about the current crisis situation. 
• Eventually, and cautiously, begin to challenge maladaptive beliefs and behaviors, and help 
the client adopt more rational and adaptive options. 

Stage V. Generate and explore alterna- • Collaboratively explore options with the client. 

tives. • Identify coping strategies that have been successful for the client in the past. 

• Help the client problem-solve strategies for confronting current crisis adaptively. 

Stage VI. Implement an action plan • There is a shift at this stage from crisis to resolution. 

• Develop a concrete plan of action to deal directly with the current crisis. 

• Having a concrete plan restores the client's equilibrium and psychological balance. 

• Work through the meaning of the event that precipitated the crisis. How could it have 
been prevented? What responses may have aggravated the situation? 

Stage VII. Follow-up. • Plan a follow-up visit with the client to evaluate the postcrisis status of the client. 

• Beneficial scheduling of follow-up visits include 1 -month and 1-year anniversaries of the 
crisis event. 

Source: Adapted from Roberts and Ottens (2005). 

Guide the individual through a problem-solving 
process by which he or she may move in the direc- 
tion of positive life change: 

Help the individual confront the source of the 
problem that is creating the crisis response. 
Encourage the individual to discuss changes he 
or she would like to make. Jointly determine 
whether or not desired changes are realistic. 


Coping mechanisms are highly individual and the 
choice ultimately must be made by the client. The 
nurse may offer suggestions and provide guid- 
ance to help the client identify coping mechanisms 
that are realistic for him or her and that can pro- 
mote positive outcomes in a crisis situation. 

Encourage exploration of feelings about aspects 
that cannot be changed, and explore alternative 
ways of coping more adaptively in these situations. 

• Discuss alternative strategies for creating changes 
that are realistically possible. 

• Weigh benefits and consequences of each alternative. 

• Assist the individual to select alternative coping strat- 
egies that will help alleviate future crisis situations. 

• Identify external support systems and new social 
networks from whom the individual may seek as- 
sistance in times of stress. 

Phase 4. Evaluation of Crisis Resolution 
and Anticipatory Planning 

To evaluate the outcome of crisis intervention, a reas- 
sessment is made to determine if the stated objective 
was achieved: 

• Have positive behavioral changes occurred? 

• Has the individual developed more adaptive coping 
strategies? Have they been effective? 

2338_Ch10_180-203.indd 186 

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• Has the individual grown from the experience by 
gaining insight into his or her responses to crisis 

• Does the individual believe that he or she could 
respond with healthy adaptation in future stressful 
situations to prevent crisis development? 

• Can the individual describe a plan of action for 
dealing with stressors similar to the one that pre- 
cipitated this crisis? 

During the evaluation period, the nurse and client 
summarize what has occurred during the interven- 
tion. They review what the individual has learned 
and "anticipate" how he or she will respond in 
the future. A determination is made regarding 
follow-up therapy; if needed, the nurse provides 
referral information. 



Nurses must be aware of the symptoms associated with 
anger and aggression to make an accurate assessment 
of a crisis. Because the best intervention is prevention, 
risk factors for assessing violence potential are also 


Anger can be associated with a number of typical be- 
haviors, including (but not limited to) the following: 

• Frowning facial expression 

• Clenched fists 

• Low-pitched verbalizations forced through clenched 

• Yelling and shouting 

• Intense eye contact or avoidance of eye contact 

• Easily offended 

• Defensive response to criticism 

• Passive- aggressive behaviors 

• Emotional overcontrol with flushing of the face 

• Intense discomfort; continuous state of tension 

Anger has been identified as a stage in the grieving 
process. Individuals who become fixed in this stage 
may become depressed. In this instance, the anger 
is turned inward as a way for the individual to main- 
tain control over the pent-up anger. Because of the 
negative connotation to the word anger, some clients 
will not acknowledge that what they are feeling is 

anger. These individuals need assistance to recognize 
their true feelings and to understand that anger is 
a perfectly acceptable emotion when it is expressed 


Aggression can arise from a number of feeling states, 
including anger, anxiety, guilt, frustration, or suspi- 
ciousness. Aggressive behaviors can be classified as mild 
(e.g., sarcasm), moderate (e.g., slamming doors), severe 
(e.g., threats of physical violence against others), or 
extreme (e.g., physical acts of violence against others). 
Aggression may be associated with (but not limited to) 
the following defining characteristics: 

• Pacing, restlessness 

• Tense facial expression and body language 

• Verbal or physical threats 

• Loud voice, shouting, use of obscenities, argu- 

• Threats of homicide or suicide 

• Increase in agitation, with overreaction to environ- 
mental stimuli 

• Panic anxiety, leading to misinterpretation of the 

• Disturbed thought processes; suspiciousness 

• Angry mood, often disproportionate to the situation 

Kassinove and Tafrate (2002) state, "In contrast to 
anger, aggression is almost always goal directed and 
has the aim of harm to a specific person or object. 
Aggression is one of the negative outcomes that may 
emerge from general arousal and anger" (pp. 40, 50). 

Intent is a requisite in the definition of aggression. 
It refers to behavior that is intended to inflict harm or 
destruction. Accidents that lead to unintentional harm 
or destruction are not considered aggression. 

Assessing Risk Factors 

Prevention is the key issue in the management of 
aggressive or violent behavior. The individual who 
becomes violent usually feels an underlying help- 
lessness. Three factors that have been identified as 
important considerations in assessing for potential 
violence include: 

1 . Past history of violence 

2 . Client diagnosis 

3. Current behavior 

Past history of violence is widely recognized as a ma- 
jor risk factor for violence in a treatment setting. Also 

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highly correlated with assaultive behavior is diagnosis. 
Diagnoses that have a strong association with violent 
behavior are schizophrenia, major depression, bipo- 
lar disorder, and substance use disorders (Friedman, 
2006). Substance abuse, in addition to mental illness, 
compounds the increased risk of violence. Dementia 
and antisocial, borderline, and intermittent explosive 
personality disorders have also been associated with a 
risk for violent behavior. 

Novitsky, Julius, and Dubin (2009) state: 

The successful management of violence is predicated 
on an understanding of the dynamics of violence. A 
patient's threatening behavior is commonly an over- 
reaction to feelings of impotence, helplessness, and 
perceived or actual humiliation. Aggression rarely 
occurs suddenly and unexpectedly (p. 50) 

They describe a "prodromal syndrome" that is 
characterized by anxiety and tension, verbal abuse 
and profanity, and increasing hyperactivity. These es- 
calating behaviors usually do not occur in stages, but 
most often overlap and sometimes occur simultane- 
ously. Behaviors associated with this prodromal stage 
include rigid posture; clenched fists and jaws; grim, 
defiant affect; talking in a rapid, raised voice; argu- 
ing and demanding; using profanity and threatening 
verbalizations; agitation and pacing; and pounding 
and slamming. 

Most assaultive behavior is preceded by a period of 
increasing hyperactivity. Behaviors associated with the 
prodromal syndrome should be considered emergent 
and demand immediate attention. Keen observation 
skills and background knowledge for accurate assess- 
ment are critical factors in predicting potential for vio- 
lent behavior. 

Diagnosis/Outcome Identification 

NANDA International does not include a separate 
nursing diagnosis for anger. The nursing diagnosis of 
dysfunctional grieving may be used when anger is ex- 
pressed inappropriately and the etiology is related to 
a loss. 

The following nursing diagnoses may be considered 
for clients demonstrating inappropriate expression of 
anger or aggression: 

• Ineffective coping related to negative role modeling 
and dysfunctional family system evidenced by yell- 
ing, name calling, hitting others, and temper tan- 
trums as expressions of anger. 

• Risk for self-directed or other-directed violence re- 
lated to having been nurtured in an atmosphere of 
violence; history of violence. 

Outcome Criteria 

The following criteria may be used for measurement 
of outcomes in the care of the client needing assistance 
with management of anger and aggression. 

The Client: 

• Is able to recognize when he or she is angry and 
seeks out staff to talk about his or her feelings. 

• Is able to take responsibility for own feelings of 

• Demonstrates the ability to exert internal control 
over feelings of anger. 

• Is able to diffuse anger before losing control. 

• Uses the tension generated by the anger in a con- 
structive manner. 

• Does not cause harm to self or others. 

• Is able to use steps of the problem-solving process 
rather than becoming violent as a means of seeking 


In Table 10-2, a plan of care is presented for the client 
who expresses anger inappropriately. Goals of care and 
appropriate nursing interventions with rationales are 
included for each diagnosis. 


Evaluation consists of reassessment to determine if the 
nursing interventions have been successful in achiev- 
ing the objectives of care. The following questions 
may provide information to determine the success of 
working with a client exhibiting inappropriate expres- 
sion of anger. 

• Is the client able to recognize when he or she is an- 
gry now? 

• Can the client take responsibility for these feelings 
and keep them in check without losing control? 

• Does the client seek out staff to talk about feelings 
when they occur? 

• Is the client able to transfer tension generated by 
the anger into constructive activities? 

• Has harm to client and others been avoided? 

• Is the client able to solve problems adaptively without 
undue frustration and without becoming violent? 


Although there are many definitions of disaster, a 
common feature is that the event overwhelms local 
resources and threatens the function and safety of the 
community (Norwood, Ursano, & Fullerton, 2000). 

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Ta b 1 e 1 0-2 Care Plan for the Individual Who Expresses Anger Inappropriately 


RELATED TO: (Possible) negative role modeling; dysfunctional family system 

EVIDENCED BY: Yelling, name calling, hitting others, and temper tantrums as expressions of anger 

Outcome Criteria Nursing Interventions 


Client will be able to recognize anger 1 . Remain calm when dealing with an 
in self and take responsibility before angry client, 
losing control. 

1 . Anger expressed by the nurse will 
most likely incite increased anger 
in the client. 

2. Set verbal limits on behavior. 

Clearly delineate the consequences 
of inappropriate expression of 
anger and always follow through. 

2 . Consistency in enforcing the 

consequences is essential if positive 
outcomes are to be achieved. In- 
consistency creates confusion and 
encourages testing of limits. 

3 . Have the client keep a diary of an- 
gry feelings, what triggered them, 
and how they were handled. 

3. This provides a more objective 
measure of the problem. 

4. Avoid touching the client when he 
or she becomes angry. 

4. The client may view touch as 
threatening and could become 

5. Help the client determine the true 
source of the anger. 

5. Many times anger is being 
displaced onto a safer object or 
person. If resolution is to occur, the 
first step is to identify the source of 
the problem. 

6. It may be constructive to ignore 
initial derogatory remarks by the 

6. Lack of feedback often extinguish- 
es an undesirable behavior. 

7. Help the client find alternate ways 
of releasing tension, such as physi- 
cal outlets, and more appropriate 
ways of expressing anger, such as 
seeking out staff when feelings 

7. Client will likely need assistance to 
problem-solve more appropriate 
ways of behaving. 

8. Role model appropriate ways of 
expressing anger assertively, such 
as, "I dislike being called names. I 
get angry when I hear you saying 
those things about me." 

8. Role modeling is one of the 
strongest methods of learning. 


RELATED TO: (Possibly) having been nurtured in an atmosphere of violence; history of violence 

Outcome Criteria Nursing Interventions 


• The client will not harm self 1 . Observe client for escalation of an- 
or others. ger (called the prodromal syndrome): 

• The client will verbalize increased motor activity, pounding 
anger rather than hit others. s amming, tense posture, defiant affect, 

clenched teeth and nsts, arguing, de- 
manding, and challenging or threatening 

1 . Violence may be prevented if risks 
are identified in time. 

Continued on following page 

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Table 10- 

-2 Care Plan for the Individual Who Expresses Anger Inappropriately (Continued) 

Outcome Criteria Nursing Interventions 


2. When these behaviors are observed, first 

2 . The initial consideration must be 

ensure that sufficient staff are available 

having enough help to diffuse a 

to help with a potentially violent situa- 

potentially violent situation. Client 

tion. Attempt to defuse the anger begin- 

rights must be honored, while pre- 

ning with the least restrictive means. 

venting harm to client and others. 

3 . Techniques for dealing with aggression 

3 . Aggression control techniques pro- 


mote safety and reduce risk of harm 
to client and others: 

(S) a. Talking down. Say, "John, you seem 

a. Promotes a trusting relationship 

very angry. Let's go to your room and 

and may prevent the client's anxi- 

talk about it." (Ensure that client does 

ety from escalating. 

not position self between door and 


(j%) b. Physical outlets. "Maybe it would help 

b. Provides effective way for client 

if you punched your pillow or the 

to release tension associated with 

punching bag for a while" or "I'll stay 

high levels of anger. 

here with you if you want." 

c. Medication. If agitation continues to 

c. Tranquilizing medication may 

escalate, offer client choice of tak- 

calm client and prevent violence 

ing medication voluntarily. If he or 

from escalating. 

she refuses, reassess the situation to 

determine if harm to self or others is 


d. Call for assistance. Remove self and 

d. Client and staff safety are of pri- 

other clients from the immediate area. 

mary concern. 

Call violence code, push "panic" but- 

ton, call for assault team, or institute 

measures established by institution. 

Sufficient staff to indicate a show of 

strength may be enough to deescalate 

the situation, and client may agree to 

take the medication. 

e. Restraints. If client is not calmed by 

e. Clients who do not have internal 

"talking down" or by medication, use of 

control over their own behavior 

mechanical restraints and/or seclusion 

may require external controls, 

may be necessary. Be sure to have 

such as mechanical restraints, in 

sufficient staff available to assist. 

order to prevent harm to self or 

Figures 10-3, 10-4, and 10-5 illustrate 


ways in which staff can safely and ap- 

propriately deal with an out-of-control 

client. Follow protocol for restraints/ 

seclusion established by the institution. 

The Joint Commission requires that 

an order be initiated by a licensed in- 

dependent practitioner within 1 hour of 

the initiation of the restraint or seclu- 

sion. In-person evaluations must be 

completed within 4 hours for adults 

ages 1 8 and older and within 2 hours 

for children ages 1 7 and younger. 

Restraints should be used as a last 

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Ta b I e 1 0-2 Care Plan for the Individual Who Expresses Anger Inappropriately (Continued) 

Outcome Criteria 

Nursing Interventions 

resort, after all other interventions 
have been unsuccessful, and the client 
is clearly at risk of harm to self or 


FIGURE 10-3 Walking a client 
to the seclusion room. 

FIGURE 10-4 Staff restraint of 
a client in supine position. The client's 
head is controlled to prevent biting. 

FIGURE 1 0-5 Transporting a cli- 
ent to the seclusion room. 

Continued on following page 

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Ta b I e 1 0-2 Care Plan for the Individual Who Expresses Anger Inappropriately (Continued) 

Outcome Criteria 

Nursing Interventions 

f. Observation and documentation. 
Observe the client in restraints every 
1 5 minutes (or according to institu- 
tional policy). Ensure that circulation to 
extremities is not compromised (check 
temperature, color, pulses). Assist client 
with needs related to nutrition, hydra- 
tion, and elimination. Position client so 
that comfort is facilitated and aspira- 
tion can be prevented. Document all 

g. Ongoing assessment. As agitation 
decreases, assess client's readiness for 
restraint removal or reduction. With 
assistance from other staff members, 
remove one restraint at a time, while 
assessing client's response. This 
minimizes the risk of injury to 
client and staff. 

h. Staff debriefing. It is important when a 
client loses control for staff to follow- 
up with a discussion about the situa- 
tion. Tardiff (2003) states, "The 
violent episode should be discussed 
in terms of what happened, what 
would have prevented it, why seclusion 
or restraint was used (if it was), and 
how the client or the staff felt in 
terms of using seclusion and restraint." 
It is also important to discuss the 
situation with other clients who wit- 
nessed the episode. It is important 
that they understand what happened. 
Some clients may fear that they 
could be secluded or restrained at 
some time for no apparent reason. 


f. Client well-being is a nursing 

g. Gradual removal of the restraints 
allows for testing of the client's self- 
control. Client and staff safety are of 
primary concern. 

h. Debriefing helps to diminish the 
emotional impact of the interven- 
tion. Mutual feedback is shared, and 
staff has an opportunity to process 
and learn from the event. 

A violent disaster, whether natural or manmade, may 
leave devastation of property or life. Such tragedies 
also leave victims with a damaged sense of safety and 
well-being and varying degrees of emotional trauma 
(Oklahoma State Department of Health [OSDH], 
2001). Children, who lack life experiences and coping 
skills, are particularly vulnerable. Their sense of order 
and security has been seriously disrupted, and they 
are unable to understand that the disruption is time 
limited and that their world will eventually return to 


Background Assessment Data 

Individuals respond to traumatic events in many ways. 
Grieving is a natural response following any loss, and 
it may be more extreme if the disaster is directly ex- 
perienced or witnessed (OSDH, 2001). The emotional 
effects of loss and disruption may show up immediately 
or may appear weeks or months later. 

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Psychological and behavioral responses common in 
adults following trauma and disaster include anger; dis- 
belief; sadness; anxiety; fear; irritability; arousal; numb- 
ing; sleep disturbance; and increases in alcohol, caf- 
feine, and tobacco use (Norwood et al, 2000). Preschool 
children commonly experience separation anxiety, re- 
gressive behaviors, nightmares, and hyperactive or with- 
drawn behaviors. Older children may have difficulty 
concentrating, somatic complaints, sleep disturbances, 
and concerns about safety. Adolescents' responses are 
often similar to those of adults. 

Norwood and associates (2000) state: 

Traumatic bereavement is recognized as posing 
special challenges to survivors. While the death 
of loved ones is always painful, an unexpected and 
violent death can be more difficult to assimilate. 
Family members may develop intrusive images 
of the death based on information gleaned from 
authorities or the media. Witnessing or learning of 
violence to a loved one also increases vulnerability 
to psychiatric disorders. The knowledge that one 
has been exposed to toxins is a potent traumatic 
stressor . . . and the focus of much concern in the 
medical community preparing for responses to ter- 
rorist attacks using biological, chemical, or nuclear 
agents, (p. 214) 

Nursing Diagnoses/Outcome 

Information from the assessment is analyzed, and ap- 
propriate nursing diagnoses reflecting the immediacy 
of the situation are identified. Some nursing diagnoses 
that may be relevant include: 

• Risk for injury (trauma, suffocation, poisoning) 

• Risk for infection 

• Anxiety (panic) 

• Fear 

• Spiritual distress 

• Risk for post-trauma syndrome 

• Ineffective community coping 

The following criteria may be used for measure- 
ment of outcomes in the care of the client having expe- 
rienced a traumatic event. Timelines are individually 

The Client: 

• Experiences minimal/no injury to self 

• Demonstrates behaviors necessary to protect self 
from further injury 

• Identifies interventions to prevent/reduce risk of 

• Is free of infection 

• Maintains anxiety at manageable level 

• Expresses beliefs and values about spiritual issues 

• Demonstrates ability to deal with emotional reac- 
tions in an individually appropriate manner 

• Demonstrates an increase in activities to improve 
community functioning 


Table 10-3 provides a plan of care for the client who 
has experienced a traumatic event. Selected nursing 
diagnoses are presented, along with outcome crite- 
ria, appropriate nursing interventions, and rationales 
for each. 


In the final step of the nursing process, a reassessment 
is conducted to determine if the nursing actions have 
been successful in achieving the objectives of care. 
Evaluation of the nursing actions for the client who 
has experienced a traumatic event may be facilitated 
by gathering information utilizing the following types 
of questions: 

• Has the client escaped serious injury, or have inju- 
ries been resolved? 

• Have infections been prevented or resolved? 

• Is the client able to maintain anxiety at manageable 

• Does he or she demonstrate appropriate problem- 
solving skills? 

• Is the client able to discuss his or her beliefs about 
spiritual issues? 

• Does the client demonstrate the ability to deal with 
emotional reactions in an individually appropriate 

• Does he or she verbalize a subsiding of the physical 
manifestations (e.g., pain, nightmares, flashbacks, 
fatigue) associated with the traumatic event? 

• Has there been recognition of factors affecting the 
community's ability to meet its own demands or 

• Has there been a demonstration of increased activi- 
ties to improve community functioning? 

• Has a plan been established and put in place to deal 
with future contingencies? 


A crisis is defined as "a sudden event in one's life that 
disturbs homeostasis, during which usual coping 

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Table 10-3 Care Plan for the Client Who Has Experienced a Traumatic Event 


RELATED TO: Real or perceived threat to physical well-being; threat of death; situational crisis; exposure 
to toxins; unmet needs 

EVIDENCED BY: Persistent feelings of apprehension and uneasiness; sense of impending doom; impaired 
functioning; verbal expressions of having no control or influence over situation, outcome, 
or self-care; sympathetic stimulation; extraneous physical movements 

Outcome Criteria Nursing Interventions 


Client will maintain anxiety at 1 . 
manageable level. 

Determine degree of anxiety/fear 
present, associated behaviors (e.g., 
laughter, crying, calm or agita- 
tion, excited/hysterical behavior, 
expressions of disbelief and/or 
self-blame), and reality of per- 
ceived threat. 

1 . Clearly understanding client's per- 
ception is pivotal to providing ap- 
propriate assistance in overcoming 
the fear. Individual may be agitated 
or totally overwhelmed. Panic 
state increases risk for client's own 
safety as well as the safely of others 
in the environment. 


Note degree of disorganization. 

2 . Client may be unable to handle 
ADLs or work requirements and 
need more intensive intervention. 


Create as quiet an area as pos- 
sible. Maintain a calm confident 
manner. Speak in even tone using 
short simple sentences. 

3. Decreases sense of confusion or 
overstimulation; enhances sense 
of safety. Helps client focus on 
what is said and reduces transmis- 
sion of anxiety. 


Develop trusting relationship 
with the client. 

4. Trust is the basis of a therapeu- 
tic nurse-client relationship and 
enables them to work effectively 


Identify whether incident has 
reactivated preexisting or 
coexisting situations (physical 
or psychological). 

5. Concerns and psychological is- 
sues will be recycled every time 
trauma is reexperienced and affect 
how the client views the current 


Determine presence of physical 
symptoms (e.g., numbness, head- 
ache, tightness in chest, nausea, 
and pounding heart). 

6. Physical problems need to be dif- 
ferentiated from anxiety symp- 
toms so appropriate treatment 
can be given. 


Identify psychological responses 
(e.g., anger, shock, acute anxiety, 
panic, confusion, denial). Record 
emotional changes. 

7. Although these are normal 
responses at the time of the 
trauma, they will recycle again 
and again until they are dealt with 


Discuss with client the perception 
of what is causing the anxiety. 

8. Increases the ability to connect 
symptoms to subjective feeling 
of anxiety, providing opportunity 
to gain insight/control and make 
desired changes. 


Assist client to correct any distor- 
tions being experienced. Share 
perceptions with client. 

9. Perceptions based on reality will 
help to decrease fearfulness. How 
the nurse views the situation may 
help client to see it differently. 


Explore with client or significant 
other the manner in which client 
has previously coped with 
anxiety-producing events. 

10. May help client regain sense of 
control and recognize significance 
of trauma. 

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Table 10-3 Care Plan for the Client Who Has Experienced a Traumatic Event (Continued) 

Outcome Criteria Nursing Interventions 


1 1 . Engage client in learning new 
coping behaviors (e.g., progres- 
sive muscle relaxation, thought 

1 1 . Replacing maladaptive behaviors 
can enhance ability to manage 
and deal with stress. Interrupting 
obsessive thinking allows client 
to use energy to address underly- 
ing anxiety, whereas continued 
rumination about the incident can 
retard recovery. 

12. Encourage use of techniques to 
manage stress and vent emotions 
such as anger and hostility. 

12. Reduces the likelihood of erup- 
tions that can result in abusive 

1 3 . Give positive feedback when 
client demonstrates better ways 
to manage anxiety and is able to 
calmly and realistically appraise 
the situation. 

1 3 . Provides acknowledgement and 
reinforcement, encouraging use of 
new coping strategies. Enhances 
ability to deal with fearful feelings 
and gain control over situation, 

promoting future successes. 

14. Administer medications as 

indicated — Antianxiety: diazepam, 
alprazolam, oxazepam; or antide- 
pressants: fluoxetine, paroxetine, 

14. Provides temporary relief of anxi- 
ety symptoms, enhancing ability 
to cope with situation. 

To lift mood and help suppress 
intrusive thoughts and explosive 


RELATED TO: Physical or psychological stress; energy-consuming anxiety; loss(es), intense suffering; 
separation from religious or cultural ties; challenged belief and value system 

EVIDENCED BY: Expressions of concern about disaster and the meaning of life and death or belief 

systems; inner conflict about current loss of normality and effects of the disaster; anger 
directed at deity; engaging in self-blame; seeking spiritual assistance 

Outcome Criteria Nursing interventions 


Client expresses beliefs and values 1 . Determine client's religious/ 
about spiritual issues. spiritual orientation, current in- 
volvement, and presence of conflicts. 

1 . Provides baseline for planning 
care and accessing appropriate 

2 . Establish environment that pro- 
motes free expression of feelings 
and concerns. Provide calm, peace- 
ful setting when possible. 

2. Promotes awareness and identifica- 
tion of feelings so they can be 
dealt with. 

3 . Listen to client's and significant 
others' expressions of anger, con- 
cern, alienation from God, belief 
that situation is a punishment for 
wrongdoing, etc. 

3 . It is helpful to understand the 
client's and significant others' 
points of view and how they are 
questioning their faith in the face 
of tragedy. 

4. Note sense of futility, feelings of 
hopelessness and helplessness, lack 
of motivation to help self. 

4. These thoughts and feelings can 
result in the client feeling para- 
lyzed and unable to move forward 
to resolve the situation. 

Continued on following page 

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Table 10- 

-3 Care Plan for the Client Who Has Experienced a Traumatic Event (Continued) 

Outcome Criteria Nursing interventions 



Listen to expressions of inability 
to find meaning in life and reason 
for living. Evaluate for suicidal 


May indicate need for farther 
intervention to prevent suicide 


Determine support systems avail- 
able to client. 


Presence or lack of support sys- 
tems can affect client's recovery. 


Ask how you can be most helpful. 
Convey acceptance of client's 
spiritual beliefs and concerns. 


Promotes trust and comfort, en- 
couraging client to be open about 
sensitive matters. 


Make time for nonjudgmental 
discussion of philosophic issues 
and questions about spiritual 
impact of current situation. 


Helps client to begin to look 
at basis for spiritual confusion. 
NOTE: There is a potential for 
care provider's belief system to 
interfere with client finding own 
way. Therefore, it is most ben- 
eficial to remain neutral and not 
espouse own beliefs. 


Discuss difference between 
grief and guilt and help client 
to identify and deal with each, 
assuming responsibility for own 
actions, expressing awareness of 
the consequences of acting out of 
false guilt. 


Blaming self for what has hap- 
pened impedes dealing with the 
grief process and needs to be 
discussed and dealt with. 


Use therapeutic communication 
skills of reflection and active- 


Helps client find own solutions to 


Encourage client to experience 
meditation, prayer, and forgive- 
ness. Provide information that 
anger with God is a normal part 
of the grieving process. 


This can help to heal past and 
present pain. 


Assist client to develop goals for 
dealing with life situation. 


Enhances commitment to goal, 
optimizing outcomes and pro- 
moting sense of hope. 


Identify and refer to resources 
that can be helpful, e.g., pastoral/ 
parish nurse or religious coun- 
selor, crisis counselor, psycho- 
therapy, Alcoholics/Narcotics 


Specific assistance may be helpful 
to recovery (e.g., relationship 
problems, substance abuse, sui- 
cidal ideation). 


Encourage participation in sup- 
port groups. 


Discussing concerns and ques- 
tions with others can help client 
resolve feelings. 

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Table 10-3 Care Plan for the Client Who Has Experienced a Traumatic Event (Continued) 


RELATED TO: Events outside the range of usual human experience; serious threat or injury to self or 
loved ones; witnessing horrors or tragic events; exaggerated sense of responsibility; 
survivor's guilt or role in the event; inadequate social support 

Outcome Criteria Nursing Interventions 


Client demonstrates ability to deal 1 . 
with emotional reactions in an indi- 
vidually appropriate manner. 

Determine involvement in event 
(e.g., survivor, significant other, 
rescue/aid worker, health-care 
provider, family member). 


All those concerned with a 
traumatic event are at risk for 
emotional trauma and have needs 
related to their involvement in the 
event. NOTE: Close involvement 
with victims affects individual 
responses and may prolong emo- 
tional suffering. 


Evaluate current factors as- 
sociated with the event, such as 
displacement from home due to 
illness/injury, natural disaster, or 
terrorist attack. Identify how cli- 
ent's past experiences may affect 
current situation. 


Affects client's reaction to current 
event and is basis for planning 
care and identifying appropriate 
support systems and resources. 


Listen for comments of taking on 
responsibility (e.g., "I should have 
been more careful or gone back to 
get her."). 


Statements such as these are 
indicators of "survivor's guilt" and 
blaming self for actions. 


Identify client's current coping 


Noting positive or negative cop- 
ing skills provides direction for 


Determine availability and useful- 
ness of client's support systems, 
family, social contacts, and com- 
munity resources. 


Family and others close to the 
client may also be at risk and 
require assistance to cope with the 


Provide information about signs 
and symptoms of post- trauma 
response, especially if individual is 
involved in a high-risk 


Awareness of these factors helps 
individual identify need for assist- 
ance when signs and symptoms 


Identify and discuss client's 
strengths as well as vulnerabilities. 


Provides information to build on 
for coping with traumatic 


Evaluate individual's perceptions 
of events and personal signifi- 
cance (e.g., rescue worker trained 
to provide lifesaving assistance 
but recovering only dead bodies). 


Events that trigger feelings of 
despair and hopelessness may be 
more difficult to deal with, and 
require long-term interventions. 


Provide emotional and physical 
presence by sitting with client/ 
significant other and offering 


Strengthens coping abilities 


Encourage expression of feelings. 
Note whether feelings expressed 
appear congruent with events 


It is important to talk about the 
incident repeatedly. Incongruities 
may indicate deeper conflict and 
can impede resolution. 

Continued on following page 

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Table 10-3 Care Plan for the Client Who Has Experienced a Traumatic Event (Continued) 

Outcome Criteria Nursing Interventions 


1 1 . Note presence of nightmares, 
reliving the incident, loss of ap- 
petite, irritability, numbness and 
crying, and family or relationship 

1 1 . These responses are normal in 
the early postincident time frame. 
If prolonged and persistent, they 
may indicate need for more inten- 
sive therapy. 

12. Provide a calm, safe environment. 

12. Helps client deal with the disrup- 
tion in his or her life. 

1 3 . Encourage and assist client in 
learning stress-management 

1 3 . Promotes relaxation and helps 
individual exercise control over 
self and what has happened. 

14. Recommend participation in 
debriefing sessions that may be 
provided following major disaster 

14. Dealing with the stresses promptly 
may facilitate recovery from the 
event or prevent exacerbation. 

15. Identify employment, community 
resource groups. 

15. Provides opportunity for ongoing 
support to deal with recurrent 
feelings related to the trauma. 

16. Administer medications as 

indicated, such as antipsychotics 
(e.g., chlorpromazine, haloperi- 
dol, olanzapine, or quetiapine) or 
carbamazepine (Tegretol). 

16. Low doses may be used for reduc- 
tion of psychotic symptoms when 
loss of contact with reality occurs, 
usually for clients with especially 
disturbing flashbacks. 

Carbamazepine may be used to 
alleviate intrusive recollections or 
flashbacks, impulsivity, and violent 


RELATED TO: Natural or manmade disasters (earthquakes, tornados, floods, reemerging infectious agents, 
terrorist activity); ineffective or nonexistent community systems (e.g., lack of or inadequate 
emergency medical system, transportation system, or disaster-planning systems) 

EVIDENCED BY: Deficits of community participation; community does not meet its own expectations; 
expressed vulnerability; community powerlessness; stressors perceived as excessive; 
excessive community conflicts; high illness rates 

Outcome Criteria Nursing Interventions 


Client demonstrates an increase in 1 . Evaluate community activities that 
activities to improve community are related to meeting collective 
functioning. needs within the community itself 

and between the community and 
the larger society. Note immediate 
needs, such as health-care, food, 
shelter, funds. 

1 . Provides a baseline to determine 
community needs in relation to 
current concerns or threats. 

2 . Note community reports of func- 
tioning, including areas of weak- 
ness or conflict. 

2 . Provides a view of how the com- 
munity itself sees these areas. 

3 . Identify effects of related factors 
on community activities. 

3 . In the face of a current threat, local 
or national, community resources 
need to be evaluated, updated, 
and given priority to meet the 
identified need. 

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Table 10-3 

Care Plan for the Client Who Has Experienced a Traumatic Event (Continued) 

Outcome Criteria Nursing Interventions 



Determine availability and use 
of resources. Identify unmet de- 
mands or needs of the community. 


Information necessary to identify 
what else is needed to meet the 
current situation. 


Determine community strengths. 


Promotes understanding of the 
ways in which the community is 
already meeting the identified 


Encourage community members/ 
groups to engage in problem- 
solving activities. 


Promotes a sense of working 
together to meet the needs. 


Develop a plan jointly with the 
members of the community to 
address immediate needs. 


Deals with deficits in support of 
identified goals. 


Create plans managing interac- 
tions within the community itself 
and between the community and 
the larger society. 


Meets collective needs when 
the concerns/threats are shared 
beyond a local community. 


Make information accessible to 
the public. Provide channels for 
dissemination of information to 
the community as a whole (e.g., 
print media, radio/television 
reports and community bulletin 
boards, internet sites, speaker's 
bureau, reports to committees/ 
councils/advisory boards). 


Readily available accurate infor- 
mation can help citizens deal with 
the situation. 


Make information available in 
different modalities and geared to 
differing educational levels/ 
cultures of the community. 


Using languages other than Eng- 
lish and making written materials 
accessible to all members of the 
community will promote under- 


Seek out and evaluate needs of 
underserved populations. 


Homeless and those residing in 
lower income areas may have 
special requirements that need 
to be addressed with additional 

Source: Doenges, M.E., Moorhouse, M.E, & Murr, A.C. (2010). Nursing care plans: Guidelines for individualizing client care across 
the life span (8th ed.). Philadelphia: EA. Davis. With permission. 

mechanisms cannot resolve the problem" (Lagerquist, 
2006, p. 351). 

I All individuals experience crises at one time or an- 
other. This does not necessarily indicate psychopa- 

Crises are precipitated by specific identifiable events 
and are determined by an individual's personal per- 
ception of the situation. 

Crises are acute rather than chronic and generally 
last no more than a few weeks to a few months. 

Crises occur when an individual is exposed to a 
stressor and previous problem-solving techniques 
are ineffective. This causes the level of anxiety to 
rise. Panic may ensue when new techniques are tried 
and resolution fails to occur. 

I Six types of crises have been identified. They are 
dispositional crises, crises of anticipated life tran- 
sitions, crises resulting from traumatic stress, 
maturation/developmental crises, crises reflect- 
ing psychopathology, and psychiatric emergencies. 

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The type of crisis determines the method of inter- 
vention selected. 

Crisis intervention is designed to provide rapid as- 
sistance for individuals who have an urgent need. 
The minimum therapeutic goal of crisis interven- 
tion is psychological resolution of the individual's 
immediate crisis and restoration to at least the level 
of functioning that existed before the crisis period. A 
maximum goal is improvement in functioning above 
the precrisis level. 

Nurses regularly respond to individuals in crisis in 
all types of settings. Nursing process is the vehicle 
by which nurses assist individuals in crisis with a 
short-term problem-solving approach to change. 
A four-phase technique of crisis intervention is 
assessment/analysis, planning of therapeutic inter- 
vention, intervention, and evaluation of crisis reso- 
lution and anticipatory planning. 
Through this structured method of assistance, nurses 
help individuals in crisis to develop more adaptive 

coping strategies for dealing with stressful situations 
in the future. 

Intervention in crises situations that involve anger 
and aggression by a client requires special knowl- 
edge and skills on the part of the nursing staff. 

■ Nurses must be aware of the symptoms associated 
with anger and aggression to make an accurate 

Prevention is the key issue in the management of 
aggressive or violent behavior. Three elements have 
been identified as key risk factors in the potential 
for violence: (1) past history of violence, (2) client 
diagnosis, and (3) current behaviors. 

■ Nurses have many important skills that can assist 
individuals and communities in the wake of trau- 
matic events. Nursing interventions presented in 
this chapter were developed for the nursing diag- 
noses of panic anxiety/fear, spiritual distress, risk for 
post- trauma syndrome, and ineffective community 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 

1. Which of the following is a correct assumption regarding the concept of crisis? 

a. Crises occur only in individuals with psychopathology. 

b. The stressful event that precipitates crisis is seldom identifiable. 

c. A crisis situation contains the potential for psychological growth or deterioration. 

d. Crises are chronic situations that recur many times during an individual's life. 

2. Crises occur when an individual: 

a. is exposed to a precipitating stressor. 

b. perceives a stressor to be threatening. 

c. has no support systems. 

d. experiences a stressor and perceives coping strategies to be ineffective. 

3. Amanda's mobile home was destroyed by a tornado. Amanda received only minor injuries, but is 
experiencing disabling anxiety in the aftermath of the event. This type of crisis is called: 

a. crisis resulting from traumatic stress. 

b. maturational/developmental crisis. 

c. dispositional crisis. 

d. crisis of anticipated life transitions. 

4. The most appropriate crisis intervention with Amanda would be to: 

a. encourage her to recognize how lucky she is to be alive. 

b. discuss stages of grief and feelings associated with each. 

c. identify community resources that can help Amanda. 

d. suggest that she find a place to live that provides a storm shelter. 

5. Jenny reported to the high school nurse that her mother drinks too much. She is drunk every 
afternoon when Jenny gets home from school. Jenny is afraid to invite friends over because of her 
mother's behavior. This type of crisis is called: 

a. crisis resulting from traumatic stress. 

b. maturational/developmental crisis. 

c. dispositional crisis. 

d. crisis reflecting psychopathology. 

6. The most appropriate nursing intervention with Jenny would be to: 

a. make arrangements for her to start attending Alate en meetings. 

b. help her identify the positive things in her life and recognize that her situation could be a lot 
worse than it is. 

c. teach her about the effects of alcohol on the body and that it can be hereditary. 

d. refer her to a psychiatrist for private therapy to learn to deal with her home situation. 

7. Ginger, age 19 and an only child, left 3 months ago to attend a college of her choice 500 miles away 
from her parents. It is Ginger's first time away from home. She has difficulty making decisions 
and will not undertake anything new without first consulting her mother. They talk on the phone 
almost every day. Ginger has recently started having anxiety attacks. She consults the nurse 
practitioner in the student health center. This type of crisis is called: 

a. crisis resulting from traumatic stress. 

b. dispositional crisis. 

c. psychiatric emergency. 

d. maturational/developmental crisis. 

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8. The most appropriate nursing intervention with Ginger would be to: 

a. suggest she move to a college closer to home. 

b. work with Ginger on unresolved dependency issues. 

c. help her find someone in the college town from whom she could seek assistance rather than 
calling her mother regularly. 

d. recommend that the college physician prescribe an antianxiety medication for Ginger. 

9. Marie, age 56, is the mother of five children. Her youngest child, who had been living at home 
and attending the local college, recently graduated and accepted a job in another state. Marie has 
never worked outside the home and has devoted her life to satisfying the needs of her husband 
and children. Since the departure of her last child from home, Marie has become more and more 
despondent. Her husband has become very concerned and takes her to the local mental health 
center. This type of crisis is called: 

a. dispositional crisis. 

b. crisis of anticipated life transitions. 

c. psychiatric emergency. 

d. crisis resulting from traumatic stress. 

10. The most appropriate nursing intervention with Marie from question 9 would be to: 

a. refer her to her family physician for a complete physical examination. 

b. suggest she seek outside employment now that her children have left home. 

c. identify convenient support systems for times when she is feeling particularly despondent. 

d. begin grief work and assist her to recognize areas of self- worth separate and apart from her 

1 1 . The desired outcome of working with an individual who has witnessed a traumatic event and is 
now experiencing panic anxiety is: 

a. the individual will experience no anxiety. 

b. the individual will demonstrate hope for the future. 

c. the individual will maintain anxiety at a manageable level. 

d. the individual will verbalize acceptance of self as worthy. 

12. John, age 27, was brought to the emergency department by two police officers. He smelled 
strongly of alcohol and was combative. His blood alcohol level was measured at 293 mg/dL. 
His girlfriend reports that he drinks excessively every day and is verbally and physically abusive. 
The nurses give John the nursing diagnosis of Risk for Other-directed Violence. What would be 
appropriate outcome objectives for this diagnosis? Select all that apply. 

a. The client will not verbalize anger or hit anyone. 

b. The client will verbalize anger rather than hit others. 

c. The client will not harm self or others. 

d. The client will be restrained if he becomes verbally or physically abusive. 

1 3 . John has a history of violence and is hospitalized with substance use disorder. One evening, the 
nurse hears John yelling in the dayroom. The nurse observes his increased agitation, clenched 
fists, and loud, demanding voice. He is challenging and threatening staff and the other clients. 
The nurse's priority intervention would be: 

a. call for assistance. 

b. draw up a syringe of prn haloperidol. 

c. ask John if he would like to talk about his anger. 

d. tell John that if he does not calm down, he will have to be restrained. 

f / 

2338_Ch10_180-203.indd 202 

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14. John, who has a history of verbal and physical abuse of his girlfriend, is hospitalized with 
substance use disorder. One evening, during a visit from his girlfriend, she and John are overheard 
having a loud argument. Which behavior by John would indicate he is learning to adaptively 
problem-solve his frustrations? 

a. John says to the nurse, "Give me some of that medication before I end up in restraints!" 

b. When his girlfriend leaves, John goes to the exercise room and punches on the punching bag. 

c. John says to the nurse, "I guess I'm going to have to dump that broad!" 

d. John says to his girlfriend, "You'd better leave before I do something I'm sorry for." 

15. Andrew, a New York City firefighter, and his entire unit responded to the terrorist attacks at the 
World Trade Center. Working as a team, he and his best friend, Carlo, entered the area together. 
Carlo was killed when the building collapsed. Andrew was injured, but survived. Since that time, 
Andrew has had frequent nightmares and anxiety attacks. He says to the mental health worker, 
"I don't know why Carlo had to die and I didn't!" This statement by Andrew suggests that he is 

a. spiritual distress. 

b. night terrors. 

c. survivor's guilt. 

d. suicidal ideation. 

16. Intervention with Andrew would include: 

a. encouraging expression of feelings. 

b. antianxiety medications. 

c. participation in a support group. 

d. a and c. 

e. all of the above. 


Aguilera, D.C. (1998). Crisis intervention: Theory and ? 

(8th ed.). St. Louis, MO: C.V. Mosby. 
Bateman, A., & Peternelj -Taylor, C. (1998). Crisis intervention. In 

C.A. Glod (Ed.), Contemporary psychiatric-mental health nursing: 

The brain-behavior connection. Philadelphia: F.A. Davis. 
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2010). Nursing 

care plans: Guidelines for individualizing client care across the life span 

(8th ed.). Philadelphia: F.A. Davis. 
Friedman, R.A. (2006, November 16). Violence and mental 

illness — How strong is the link? New England Journal of 

Medicine, 555(20), 2064-2066. 
Kassinove, H., & Tafrate, R.C. (2002). Anger management. 

Atascadero, CA: Impact. 
Lagerquist, S.L. (2006). Davis's NCLEX-RN Success (2nd ed.). 

Philadelphia: F.A. Davis. 
Norwood, A.E., Ursano, R.J., & Fullerton, C.S. (2000). Disaster 

psychiatry: Principles and practice. Psychiatric Quarterly, 77(3), 


Novitsky, M.A.Julius, R.J., & Dubin, W.R. (2009). Non- 
pharmacologic management of violence in psychiatric 
emergencies. Primary Psychiatry, 16(9), 49-53. 

Oklahoma State Department of Health [OSDH]. (2001). After the 
storm: Helping families cope with disaster. Oklahoma City: OSDH. 

Roberts, A.R., & Ottens, A.J. (2005). The seven-stage crisis inter- 
vention model: A road map to goal attainment, problem solving, 
and crisis resolution. Brief Treatment and Crisis Intervention 5(4), 

Tardiff, K. (2003). Violence. In R.E. Hales, S.C. Yvdofsky, & J.A. 
Talbott (Eds.), Textbook of clinical psychiatry (4th ed.). Washington, 
DC: American Psychiatric Publishing. 

Winston, A. (2008). Supportive psychotherapy. In R.E. Hales, 
S.C. Yudofsky, & G.O. Gabbard (Eds.), Textbook of psychiatry 
(5th ed.). Washington, DC: American Psychiatric Publishing. 


Baldwin, B.A. (1978, July). A paradigm for the classification of 
emotional crises: Implications for crisis intervention. American 
Journal of Orthopsychiatry, 48(3), 53 8-5 5 1 . 

Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic 

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H A P T E R 

Complementary and 
Psychosocial Therapies 










allopathic medicine 


alternative medicine 


automatic thoughts 




chiropractic medicine 


cognitive therapy 

reality therapy 

free association 






complementary medicine 




After reading this chapter, the student will be able to: 

1. Compare and contrast various types 
of conventional and alternative 

2. Describe the philosophies behind 
various complementary therapies, 
including herbal medicine, acupressure 
and acupuncture, diet and nutrition, chi- 
ropractic medicine, therapeutic 
touch and massage, yoga, and pet 


3. Discuss the historical background of vari- 
ous complementary therapies. 

4. Describe the techniques used in various 
complementary therapies. 

5. Discuss objectives and therapeutic strate- 
gies of various psychosocial therapies, 
including individual psychotherapy, 
assertiveness training, relaxation therapy, 
and cognitive therapy. 

2338_Ch11_204-230.indd 204 

8/31/10 5:59:44 PM 


Please read the chapter and answer the following questions. 

1. How do alternative medicine and comple- 
mentary medicine differ? 

2. What is the Western medical philosophy 
regarding the efficacy of acupressure and 

3. What herbal remedy has been used effec- 
tively for relief of migraine headaches? 

4. Define the process called abreaction. 


The History of Medicine 

2000 B.C. — Here, eat this root. 

A.D. 1000 — That root is heathen. Here, say this 


A.D. 1850 — That prayer is superstition. Here, drink 

this potion. 

A.D. 1940 — That potion is snake oil. Here, swallow 

this pill. 

A.D. 1985 — That pill is ineffective. Here, take this 


A.D. 2000 — That antibiotic is ineffective and 

dangerous. Here, eat this root. 

— Anonymous 

The connection between mind and body, and the 
influence of each on the other, is well recognized 
by all clinicians, and particularly by psychiatrists. 
Traditional medicine as it is currently practiced 
in the United States is based solely on scientific 
methodology. Traditional, science-based medicine, 
also known as allopathic medicine, is the type of 
medicine historically taught in U.S. medical schools. 
Many individuals today are choosing to move away 
from traditional medicine by trying a variety of alter- 
native approaches to health care. 

Some individuals do not completely abandon tradi- 
tional medicine for alternative therapies. Instead, they 

may choose to complement the conventional methods 
with the addition of alternative strategies. 

In the United States, approximately 38 percent 
of adults and 12 percent of children use some form 
of complementary or alternative therapy (National 
Institutes of Health [NIH], 2008). When prayer 
specifically for health reasons is included in the defi- 
nition of complementary and alternative medicine, 
the numbers are even higher. More than $27 billion 
a year is spent on these types of therapies in the 
United States. 

In 1991, an Office of Alternative Medicine (OAM) 
was established by the NIH to study nontraditional 
therapies and to evaluate their usefulness and their ef- 
fectiveness. Since that time, the name has been changed 
to the National Center for Complementary and Alter- 
native Medicine (NCCAM). According to the mission 
statement of NCCAM: 

NCCAM's mission is to explore complementary and 
alternative healing practices in the context of rigor- 
ous science, train CAM researchers, and disseminate 
authoritative information to the public and profes- 
sionals. (NIH, 2008, p. 4) 

Although there is no universal classification for com- 
plementary and alternative medicine (CAM), NCCAM 
has grouped CAM practices and modalities into five 
domains. Some types of practices may overlap; that is, 


Alternative Medicine 

Interventions that differ from the traditional or 
conventional biomedical treatment of disease. 
"Alternative" refers to an intervention that is used 
instead of conventional treatment. 


Complementary Medicine 

An intervention that is different from, but used in 
conjunction with, traditional or conventional medi- 
cal treatment. 


2338_Ch11_204-230.indd 205 

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they may fall within more than one domain (e.g., qigong 
is considered both part of Chinese medicine as well 
as an energy therapy). Within the five major domains, 
the practices have been subdivided into three catego- 
ries: (1) those that fall under CAM, (2) those that are 
found in conventional health care but are classified as 

behavioral medicine, and (3) those that overlap be- 
tween the two (DeSantis, 2009). A list of the NCCAM 
classification of complementary and alternative medi- 
cine practices and examples of each is presented in 
Table 11-1. Figure 11-1 shows the 10 most common 
CAM therapies among adults. 

Table 11-1 

Classification of Complementary and Alternative Medicine Practices 



I. Alternative Medical Systems 

a. Traditional oriental medicine 1 

• Acupuncture 

• Diet 

• Herbal formulas 

• Tai chi 

• Massage and 

• Qigong 


b. Traditional indigenous 

systems 1 

• Ayurevedic medicine 

• Unani-tibbi 

• Native American 

• Kampo 

• Traditional African 

• Curanderismo 

• Traditional Aboriginal 

• Siddhi 

• Central and South American 

c. Unconventional 

Western systems 

• Homeopathy 1 

• Functional medicine 1 

• Orthomolecular medicine 1 

• Environmental medicine 1 

• Antroposophically extended 

medicine 2 

d. Naturopathy 1 

• Natural systems and therapies 

II. Mind-Body Interventions 

a. Mind-body methods 

• Yoga 1 

• Hypnosis 2 

• Humor 3 

• Tai chi 1 

• Meditation 2 

• Journaling 3 

• Internal qi gong 1 

• Biofeedback 2 

• Art, music, and dance 
therapies 3 

b. Religion and spirituality 1 

• Confession 

• Soul retrieval 

• Nonlocality 

• "Special" healers 

• Nontemporality 

• Spiritual healing 

c. Social and contextual areas 

• Caring-based approaches (e.g., 

holistic nursing, pastoral care) 1 

• Intuitive diagnosis 1 

• Explanatory models 3 

• Placebo 3 

• Community-based approaches 

(e.g., Native -American "sweat" 

rituals) 3 

III. Biologically Based 

a. Phytotherapy or herbalism 1 


• Aloe vera 

• Ginseng 

• Bee pollen 

• Green tea 

• Cat's claw 

• Hawthorne 

• Dong Quai 

• Kava-kava 

• Echinacea 

• Licorice root 

• Evening primrose 

• Mistletoe 

• Feverfew 

• Peppermint oil 

• Garlic 

• Saw palmetto 

• Ginger 

• Witch hazel 

• Ginkgo biloba 

• Valerian 

2338_Ch11_204-230.indd 206 

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Table 11-1 

Classification of Complementary and Alternative Medicine Practices— cont'd 



b. Special diet therapies 1 

• Atkins 

• Asian 

• Diamond 

• Fasting 

• Kelly-Gonzalez 

• High fiber 

• Gerson 

• Macrobiotic 

• Livingston-Wheeler 

• Mediterranean 

• McDougall 

• Natural hygiene 

• Ornish 

• Paleolithic 

• Pritikin 

• Vegetarian 

• Wigmore 

c. Orthomolecular therapies 1 

Single nutrients (partial listing) 

• Ascorbic acid 

• Carotenes 

• Tocopherols 

• Folic acid 

• Niacin 

• Niacinamide 

• Pantothenic acid 

• Pyridoxine 

• Riboflavin 

• Thiamine 

• Vitamin A 

• Vitamin D 

• Vitamin K 

• Biotin 

• Choline 

• Calcium 

• Magnesium 

• Selenium 

• Potassium 

• Taurine 

• Lysine 

• Tyrosine 

• Iodine 

• Iron 

• Manganese 

• Boron 

• Silicon 

• Co-enzyme Q10 

• Carnitine 

• Probiotics 

• Glutamine 

• Glucosamine 

• Chondroitin 

• Lipoic acid 

• Amino acids 

• Melatonin 

• Fatty acids 


• Medium-chain 

d. Pharmacological, biological, 

and instrumental interventions 1 

Products (partial listing) 

• Coley's toxins 

• Enderlin products 

• Hyperbaric oxygen 

• Cartilage 

• Enzyme therapies 

• Ozone 

• Cone therapy 

• Gallo immunotherapy 

• Revici system 

• Cell therapy 

• h 2 o 2 

• Induced remission 

• Antineoplastons 

• Bee pollen 



• Apitherapy 

• Iridology 

• Bioresonance 

• MORA device 

• Chirography 

• Neural therapy 

• Electrodiagnostics 

IV. Manipulative and Body- 
Based Methods 

a. Chiropractic medicine 1 

b. Massage and bodywork 1 

• Osteopathic manipulative 

• Cranial-sacral OMT 

• Swedish massage 

• Applied kinesiology 

• Reflexology 

• Pilates method 

• Polarity 

c. Unconventional physical 
therapies 1 

• Hydrotherapy 

• Diathermy 

• Light and color therapies 

Trager bodywork 

Alexander technique 

Feldenkrais technique 

Chinese tui na massage 



Body psychotherapy 


Heat and electrotherapies 

Alternate nostril breathing 


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Table 11 

Classification of Complementary and Alternative Medicine Practices— cont'd 



V. Energy Therapies 

a. Biofield therapies 1 

• External qi gong 

• Huna 

• Healing science 

• Reiki 

• Healing touch 

• Biorelax 

• Natural healing 

• Therapeutic touch 

b. Bioelectromagnetic- 

-based Therapies 1 

• Unconventional use of electromagnetic fields for medical purposes 

1 CAM therapies. 

2 Behavioral medicine therapies. 

3 Overlapping therapies (either CAM or behavioral medicine). 
Sources: Ashar & Dobs, 2006; DeSantis, 2009; and NCCAM, 2007. 

Some health insurance companies and health main- 
tenance organizations (HMOs) appear to be bowing to 
public pressure by including alternative practitioners 
in their networks of providers for treatments such as 
acupuncture and massage therapy. Chiropractic care 
has been covered by some third-party payers for many 
years. Individuals who seek alternative therapy how- 
ever, are often reimbursed at lower rates than those 
who choose traditional practitioners. 

Client education is an important part of complemen- 
tary care. Positive lifestyle changes are encouraged, 
and practitioners serve as educators as well as treat- 
ment specialists. Complementary medicine is viewed 
as holistic health care, which deals not only with the 

physical perspective, but also the emotional and spir- 
itual components of the individual. Dr. Tom Conigli- 
one, former professor of medicine at the Oklahoma 
University Health Sciences Center, has stated: 

We must look at treating the "total person" in order 
to be more efficient and balanced within the medical 
community. Even finding doctors who are well- 
rounded and balanced has become a criteria in the 
admitting process for medical students. Medicine has 
changed from just looking at the "scientist perspec- 
tive of organ and disease" to the total perspective of 
lifestyle and real impact/results to the patient. This 
evolution is a progressive and very positive shift in 
the right direction. (Coniglione, 1998, p. 2) 









i.1 % 




1 .8% 








M // 


#* &p ^ 


FIGURE 11-1 Ten most common CAM therapies among adults. 


# *> 

2338_Ch11_204-230.indd 208 

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Terms such as harmony and balance are often associ- 
ated with complementary care. In fact, restoring har- 
mony and balance between body and mind is often the 
goal of complementary health-care approaches. 

This chapter examines various complementary 
therapies by describing the therapeutic approach and 
identifying the conditions for which the therapy is in- 
tended. Although most are not founded in scientific 
principle, they have been shown to be effective in the 
treatment of certain disorders and merit farther exam- 
ination as a viable component of holistic health care. 


A number of commonalities and contrasts exist be- 
tween complementary medicine and conventional 
health care. DeSantis (2009) states: 

Conventional medicine focuses on the physical 
or material part of the person, the body. It is con- 
cerned with the structure, function, and connec- 
tions or communication between material elements 
that compose the body, such as bones, muscles, and 
nerves. Conventional medicine generally views all 
humans as being very similar biologically. Disease 
is seen as a deviation from what is generally consid- 
ered to be a normal biological or somatic state. . . . 

In contrast, the alternative approach views the 
person-body as consisting of multiple, integrated 
elements that incorporate both the materialistic and 
nonmaterialistic aspects of existence. These ele- 
ments include the physical, spiritual, energetic, and 
social bodies. From this viewpoint, diagnostic meas- 
ures and interventions cannot be based on only one 
aspect of the person's being, but must be tailored to 
the person-body of each individual, (pp. 510, 512) 

A summary of these characteristics is presented in 
Table 11-2. 


Herbal Medicine 

The use of plants to heal is probably as old as human- 
kind. Virtually every culture in the world has relied on 
herbs and plants to treat illness. Clay tablets from about 
4000 B.C. reveal that the Sumerians had apothecaries 
for dispensing medicinal herbs. At the root of Chinese 
medicine is the Pen Tsao, a Chinese text written around 
3000 B.C., which contained hundreds of herbal reme- 
dies. When the Pilgrims came to America in the 1600s, 
they brought with them a variety of herbs to establish 

and use for medicinal purposes. The new settlers soon 
discovered that the Native Americans also had their 
own varieties of plants to use for healing. 

Many people are seeking a return to herbal remedies 
because they perceive them as being less potent than 
prescription drugs and as being free of adverse side 
effects. However, because the U.S. Food and Drug 
Administration (FDA) classifies herbal remedies as 
dietary supplements or food additives, their labels 
cannot indicate medicinal uses. They are not subject 
to FDA approval, and they lack uniform standards of 
quality control. 

Several organizations have been established to at- 
tempt regulation and control of the herbal industry. 
They include the Council for Responsible Nutrition, 
the American Herbal Association, and the American 
Botanical Council. The Commission E of the German 
Federal Health Agency is the group responsible for re- 
searching and regulating the safety and efficacy of herbs 
and plant medicines in Germany. All of the Commission 
E monographs of herbal medicines have been translated 
into English and compiled into one text (Blumenthal, 

Until more extensive testing has been completed on 
humans and animals, the use of herbal medicines must 
be approached with caution and responsibility. The 
notion that something being "natural" means it is therefore 
completely safe is a myth. In fact, some of the plants from 
which prescription drugs are derived are highly toxic 
in their natural state. Also, because of lack of regula- 
tion and standardization, ingredients may be adul- 
terated. Their method of manufacture also may alter 
potency. For example, dried herbs lose potency rapidly 
because of exposure to air. In addition, it is often safer 
to use preparations that contain only one herb. There 
is a greater likelihood of unwanted side effects with 
combined herbal preparations. 

Table 11-3 lists information about common herbal 
remedies, with possible implications for psychiatric/ 


It is important to ask the client about any herbal 
preparations he or she may be taking. The client 
may not think to mention these when questioned 
about current medications being taken. Herbals 
may interact with other medications, resulting in 
adverse physiological reactions. Document and 
report the client's history and current use of any 
herbal and over-the-counter preparations. 

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Table 11-2 

Commonalities and Contrasts Between Conventional and Complementary 
or Alternative Therapies 


Complementary /Alternative 


Plants and other natural products 


Healing/ministering care 

Individual viewed as disease category 

Individual is viewed as a unique being 



Focus is on disease and illness 

Focus is on health and wellness 

Illness treatment 

Health promotion and illness prevention 

Nutrition is adjunct and supportive to treatment 

Nutrition is the basis of health, wellness, and treatment 

Objectivism: Person is separate from his/her disease 

Subjectivism: Person is integral to the illness 



Practitioner as authority 

Practitioner as facilitator 

Practitioner paternalism/client dependency 

Practitioner as partner/person empowerment 

Positivism/materialism: Data are physically measurable 

Metaphysical: Entity is energy system or vital force 



Specialist care 


Symptom relief 

Alleviation of causative factors 

Somatic (biological and physiological) model 

Behavioral-psychosocial-spiritual model 

Science is only source of knowledge and truth 

Multiple sources of knowledge and truth 



Source: DeSantis, L. In Catalano, J. (2009). Nursing now! Today's issues, tomorrows trends (5th ed.). FA. Davis Company, 
Philadelphia, p. 511. With permission. 

Herbal Remedies 

Common Name 
(Botanical Name) 

Medicinal Uses/Possible Action 

Safety Profile 

Black cohosh (Cimicifuga 

May provide relief of menstrual cramps; im- 

Generally considered safe in low doses. Oc- 


proved mood; calming effect. Extracts from 

casionally causes gastrointestinal discomfort. 

the roots are thought to have action similar to 

Toxic in large doses, causing dizziness, nausea, 


headaches, stiffness, and trembling. Should not 
take with heart problems, concurrently with 
antihypertensives, or during pregnancy. 

Cascara sagrada (Rhamnus 

Relief of constipation. 

Generally recognized as safe; sold as over-the- 


counter drug in the United States. Should not 
be used during pregnancy. Contraindicated in 
bowel obstruction or inflammation. 

Chamomile (Matricaria 

As a tea, is effective as a mild sedative in the relief 

Generally recognized as safe when consumed in 


of insomnia. May also aid digestion, relieve 
menstrual cramps, and settle upset stomach. 

reasonable amounts. 

Echinacea (Echinacea 

Stimulates the immune system; may have value in 

Considered safe in reasonable doses. Observe for 

angustifolia and 

fighting infections and easing the symptoms of 

side effects or allergic reaction. 

Echinacea purpurea) 

colds and flu. 

Fennel (Foeniculum vulgare or 

Used to ease stomachaches and to aid digestion. 

Generally recognized as safe when consumed in 

Foeniculum officinale) 

Taken in a tea or in extracts to stimulate the 
appetites of people with anorexia (1-2 tsp seeds 
steeped in boiling water for making tea). 

reasonable amounts. 

Feverfew (Tanacetum 

Prophylaxis and treatment of migraine head- 

A small percentage of individuals may experience 


aches. Effective in either the fresh leaf or 

the adverse effect of temporary mouth ulcers. 

freeze-dried forms (2-3 fresh leaves [or equiva- 

Considered safe in reasonable doses. 

lent] per day). 

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Table 11-3 

Herbal Remedies— cont'd 

Common Name 
(Botanical Name) 

Medicinal Uses/Possible Action 

Safety Profile 

Ginger (Zingiber officinale) 

Ginkgo (Ginkgo biloba) 

Ginseng (Panax ginseng) 

Hops (Humulus lupulus) 

Kava kava (Piper methysticum) 

Passion flower (Passiflora 

Peppermint (Mentha piperita) 

Psyllium (Plantago ovata) 

Scullcap (Scutellaria lateriflora) 
St. John's wort (Hypericum 

Ginger tea to ease stomachaches and to aid diges- 
tion. Two powdered ginger root capsules have 
shown to be effective in preventing motion 

Used to treat senility, short-term memory 
loss, and peripheral insufficiency. Has been 
shown to dilate blood vessels. Usual dosage is 
120-240 mg/day. 

The ancient Chinese saw this herb as one that 
increased wisdom and longevity. Current 
studies support a possible positive effect on the 
cardiovascular system. Action not known. 

Used in cases of nervousness, mild anxiety, and 
insomnia. Also may relieve the cramping as- 
sociated with diarrhea. May be taken as a tea, 
in extracts, or capsules. 

Used to reduce anxiety while promoting mental 
acuity. Dosage: 150-300 mg bid. 

Used in tea, capsules, or extracts to treat nervous- 
ness and insomnia. Depresses the central nerv- 
ous system to produce a mild sedative effect. 

Used as a tea to relieve upset stomachs and head- 
aches and as a mild sedative. Pour boiling water 
over 1 tbsp dried leaves and steep to make a tea. 
Oil of peppermint is also used for inflammation 
of the mouth, pharynx, and bronchus. 

Psyllium seeds are a popular bulk laxative com- 
monly used for chronic constipation. 

Also found to be useful in the treatment of 

Used as a sedative for mild anxiety and nervousness. 

Used in the treatment of mild to moderate 
depression. May block reuptake of serotonin/ 
norepinephrine and have a mild monoamine 
oxidase inhibiting effect. Effective dose: 900 
mg/day. May also have antiviral, antibacterial, 
and anti-inflammatory properties. 

Generally recognized as safe in designated thera- 
peutic doses. 

Safety has been established with recommended 
dosages. Possible side effects include head- 
ache, gastrointestinal problems, and dizziness. 
Contraindicated in pregnancy and lactation 
and in patients with bleeding disorder. Possible 
compound effect with concomitant use of 
aspirin or anticoagulants. 

Generally considered safe. Side effects may 
include headache, insomnia, anxiety, skin 
rashes, diarrhea. Avoid concomitant use with 

Generally recognized as safe when consumed in 
recommended dosages. 

Scaly skin rash may occur when taken at high 
dosage for long periods. Motor reflexes and 
judgment when driving may be reduced while 
taking the herb. 

Concurrent use with central nervous system 
depressants may produce additive tranquilizing 

Reports of potential for liver damage. Investiga- 
tions continue. 

Should not be taken for longer than 3 months 
without a doctor's supervision. 

Generally recognized as safe in recommended 

Considered to be safe when consumed in desig- 
nated therapeutic dosages. 

Approved as an over-the-counter drug in the 
United States. 

Considered safe in reasonable amounts. 

Generally recognized as safe when taken at rec- 
ommended dosages. Side effects include mild 
gastrointestinal irritation that is lessened with 
food; photosensitivity when taken in high dos- 
ages over long periods. Should not be taken 
with other psychoactive medications. 


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Table 11-3 

Herbal Remedies— cont'd 

Common Name 
(Botanical Name) 

Medicinal Uses/Possible Action 

Safety Profile 

Valerian (Valeriana officinals) 

Used to treat nervousness and insomnia. Pro- 
duces restful sleep without morning "hango- 
ver." The root may be used to make a tea, or 
capsules are available in a variety of dosages. 
Mechanism of action is similar to benzodi- 
azepines, but without addicting properties. 
Daily dosage range: 100-1,000 mg. 

Generally recognized as safe when taken at rec- 
ommended dosages. Side effects may include 
mild headache or upset stomach. Taking doses 
higher than recommended may result in severe 
headache, nausea, morning grogginess, blurry 
vision. Should not be taken concurrently with 
central nervous system depressants. 

Sources: Adapted from Holt & Kouzi (2002); PDR for Herbal Medicines (2007); Pranthikanti, (2007); Sadock & Sadock (2007); 
and Trivieri & Anderson (2002). 

mental health nursing. Botanical names, medicinal 
uses, and safety profiles are included. 

Acupressure and Acupuncture 

Acupressure and acupuncture are healing tech- 
niques based on the ancient philosophies of traditional 
Chinese medicine dating back to 3000 B.C. The main 
concept behind Chinese medicine is that healing 
energy (qi) flows through the body along specific path- 
ways called meridians. It is believed that these merid- 
ians of qi connect various parts of the body in a way 
similar to the way in which lines on a road map link 
various locations. The pathways link a conglomerate 
of points, called acupoints. Therefore, it is possible 
to treat one part of the body that is distant to another 
because they are linked by a meridian. Trivieri and 
Anderson (2002) state, "The proper flow of qi along 
energy channels (meridians) within the body is crucial 
to a person's health and vitality" (p. 435). 

In acupressure, the fingers, thumbs, palms, or elbows 
are used to apply pressure to the acupoints. This pres- 
sure is thought to dissolve any obstructions in the flow 
of healing energy and to restore the body to a healthier 
functioning. In acupuncture, hair-thin, sterile, dispos- 
able, stainless-steel needles are inserted into acupoints 
to dissolve the obstructions along the meridians. The 
needles may be left in place for a specified length of 
time, they may be rotated, or a mild electric current 
may be applied. An occasional tingling or numbness is 
experienced, but little to no pain is associated with the 
treatment (NCCAM, 2009). 

The Western medical philosophy regarding acu- 
pressure and acupuncture is that they stimulate the 
body's own painkilling chemicals — the morphine-like 
substances known as endorphins. The treatment has 
been found to be effective in the treatment of asthma, 
dysmenorrhea, cervical pain, insomnia, anxiety, depres- 
sion, substance abuse, stroke rehabilitation, nausea of 
pregnancy, postoperative and chemotherapy-induced 

nausea and vomiting, tennis elbow, fibromyalgia, low 
back pain, carpal tunnel syndrome, and many other 
conditions (Council of Acupuncture and Oriental 
Medicine Associations [CAOMA], 2009a; NCCAM, 
2009; Sadock & Sadock, 2007). Recent studies suggest 
that acupuncture may aid in the treatment of cocaine 
dependence and chronic daily headaches (Avants et al, 
2000; Coeytaux et al, 2005). 

Acupuncture is gaining wide acceptance in the 
United States by both patients and physicians. This 
treatment can be administered at the same time 
other techniques are being used, such as conven- 
tional Western techniques, although it is essential 
that all health-care providers have knowledge of 
all treatments being received. Acupuncture should 
be administered by a physician or an acupuncturist 
who is licensed by the state in which the service is 
provided. Typical training for licensed acupunctur- 
ists, doctors of oriental medicine, and acupuncture 
physicians is a 3- or 4-year program of 2,500 to 
3,500 hours. Medical doctors and chiropractors who 
practice acupuncture must undergo 50 to 200 hours 
of acupuncture training. The National Commission 
for the Certification of Acupuncture and Oriental 
Medicine (NCCAOM) is attempting to set minimal 
competency standards in the United States through 
certification by their organization. A number of 
states have adopted NCCAOM's examination 
as part of their licensing criteria. Others, such as 
California, have their own licensing examination 
and set higher standards than those established by 
NCCAOM (CAOMA, 2009b). 

Diet and Nutrition 

The value of nutrition in the healing process has long 
been underrated. Lutz and Przytulski (2006) state: 

Today many diseases are known to be linked to 
lifestyle behaviors such as smoking, lack of adequate 
physical activity, and poor nutritional habits. The 

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World Health Organization (WHO) reports that 
nearly one-third of early death and disability stems 
from nutritional or dietary causes. Healthcare provid- 
ers emphasize the relationship between lifestyle and 
the risk of disease. Many people, at least in industrial- 
ized countries, are increasingly managing their health 
problems and making personal commitments to lead 
healthier lives. Nutrition is, in part, a preventive sci- 
ence. Given sufficient resources, how and what one 
eats is a lifestyle choice, (p. 4) 

Individuals select the foods they eat based on a 
number of factors, not the least of which is enjoy- 
ment. Eating must serve social, cultural, as well as nu- 
tritional needs. The U.S. Departments of Agriculture 
(USDA) and Health and Human Services (USDHHS) 
have collaborated on a set of guidelines to help indi- 
viduals understand what types of foods to eat and the 
healthy lifestyle they need to pursue in order to pro- 
mote health and prevent disease. Following is a list of 
key recommendations from these guidelines (USDA/ 
USDHHS, 2005). 

Adequate Nutrients Within Calorie 

• Consume a variety of nutrient-dense foods and 
beverages within and among the basic food groups 
while choosing foods that limit the intakes of fat, 
cholesterol, added sugars, salt, and alcohol. 

• Meet recommended intakes within energy needs 
by adopting a balanced eating pattern, such as the 
guidelines in Table 1 1-4, which are taken from the 
USDA Food Pyramid. Table 11-5 provides a sum- 
mary of information about essential vitamins and 

Weight Management 

• Maintain body weight in a healthy range; balance 
calories from foods and beverages with calories 

• To prevent gradual weight gain over time, make 
small decreases in food and beverage calories and 
increase physical activity. 

Physical Activity 

• Engage in regular physical activity and reduce sed- 
entary activities to promote health, psychological 
well-being, and a healthy body weight. 

• To reduce the risk of chronic disease in adulthood, 
engage in at least 30 minutes of moderate-intensity 

physical activity, above usual activity, at work or 
home on most days of the week. 

• To help manage body weight and prevent gradu- 
al, unhealthy body weight gain in adulthood, en- 
gage in approximately 60 minutes of moderate- to 
vigorous-intensity activity on most days of the week 
while not exceeding caloric intake requirements. 

• To sustain weight loss in adulthood, participate in at 
least 60 to 90 minutes of daily moderate-intensity 
physical activity while not exceeding caloric intake 

• Achieve physical fitness by including cardiovascu- 
lar conditioning, stretching exercises for flexibility, 
and resistance exercises or calisthenics for muscle 
strength and endurance. 

Food Groups to Encourage 

• Fruits and vegetables: Choose a variety of fruits 
and vegetables each day. In particular, select from all 
five vegetable subgroups several times a week. 

• Whole grains: Half the daily servings of grains 
should come from whole grains. 

• Milk and milk products: Daily choices of fat- free 
or low-fat milk or milk products are important. 
To help meet calcium needs, nondairy calcium- 
containing alternatives may be selected by individ- 
uals with lactose intolerance or those who choose 
to avoid all milk products (e.g., vegans). 

Food Groups to Moderate 

• Fats: Keep total fat intake between 20 and 35 per- 
cent of calories, with most fats coming from sources 
of polyunsaturated and monounsaturated fatty ac- 
ids, such as fish, nuts, and vegetable oils. Consume 
less than 1 percent of calories from saturated fat- 
ty acids and less than 300 mg/day of cholesterol, 
and keep trans fatty acid consumption as low as 

• Carbohydrates: Carbohydrate intake should com- 
prise 45 to 64 percent of total calories, with the 
majority coming from fiber- rich foods. Important 
sources of nutrients from carbohydrates include 
fruits, vegetables, whole grains, and milk. Added 
sugars, caloric sweeteners, and refined starches 
should be used prudently. 

• Sodium chloride: Consume less than 2,300 milli- 
grams (approximately 1 teaspoon of salt) of sodium 
per day. Choose and prepare foods with little salt. At 
the same time, consume potassium-rich foods, such 
as fruits and vegetables. 

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Table 11 

Sample USDA Food Guide at the 2,000-Calorie Level 

Food Groups and Subgroups 

Fruit Group 

Vegetable Group 


Grain Group 

USDA Food Guide Daily Amount 

2 cups (4 servings) 

2.5 cups (5 servings) 

• Dark green vegetables: 3 cups/week 

• Orange vegetables: 2 cups/week 

• Legumes (dry beans/peas): 3 cups/week 

• Starchy vegetables: 3 cups/week 

• Other vegetables: 6.5 cups/week 

6 oz equivalents 

• Whole grains: 3 oz equivalents 

• Other grains: 3 oz equivalents 

Examples/Equivalent Amounts 

Vi cup equivalent is: 

• Vi cup fresh, frozen, or canned fruit 

• 1 medium fruit 

• l A cup dried fruit 

• Vi cup fruit juice 

Vi cup equivalent is: 

• Vi cup cut up raw or cooked vegetable 

• 1 cup raw leafy vegetable 

• Vi cup vegetable juice 

1 oz equivalent is: 

• 1 slice bread 

• 1 cup dry cereal 

• Vi cup cooked rice, pasta, cereal 

Meat and Beans Group 

5.5 oz equivalents 

1 oz equivalent is: 

• 1 oz cooked lean meat, poultry, or fish 

• 1 egg 

• l A cup cooked dry beans or torn 

• 1 tbsp peanut butter 

• Vi oz nuts or seeds 

Milk Group 

3 cups 

1 cup equivalent is: 

• 1 cup low-fat/fat-free milk 

• 1 cup low-fat/fat-free yogurt 

• 1 Vi oz low-fat or fat-free natural cheese 

• 2 oz low-fat or fat-free processed cheese 

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Table 11-4 

Sample USDA Food Guide at the 2,000-Calorie Level -cont'd 

Food Groups and Subgroups 

USDA Food Guide Daily Amount Exam pies/ Equivalent Amounts 


24 g (6 tsp) 

1 tsp equivalent is: 

• 1 tbsp low-fat mayonnaise 

• 2 tbsp light salad dressing 

• 1 tsp vegetable oil 

• 1 tsp soft margarine with zero trans fat 

Discretionary Calorie Allowance 

267 calories 

Example of distribution: 

• Solid fats 18 g (e.g., saturated and trans 

• Added sugars 32 g (8 tsp) (e.g., sweet- 
ened cereals) 

1 added sugar equivalent is: 

• Vi oz jelly beans 

• 8 oz lemonade 
Examples of solid fats: 

• Fat in whole milk/ice cream 

• Fatty meats 

Essential oils (above) are not considered 
part of the discretionary calories 

Source: USDA/USDHHS (2005). 

Table 11-5 

Essential Vitamins and Minerals 



DRI (UL)* 

Food Sources 


Vitamin A 

Vitamin D 

Vitamin E 

Prevention of night 
blindness; calcifica- 
tion of growing 
bones; resistance to 

Promotes absorption 
of calcium and phos- 
phorus in the small 
intestine; prevention 
of rickets 

An antioxidant that pre- 
vents cell membrane 

Men: 900 ug (3,000 ug) 
Women: 700 ug (3,000 ug) 

Men and women: 5 ug 

(50 ug) 
(5 to 10 for ages 50-70 and 


Men and women: 1 5 mg 
(1,000 mg) 

Liver, butter, 
cheese, whole 
milk, egg yolk, 
fish, green leafy 
vegetables, car- 
rots, pumpkin, 
sweet potatoes 

Fortified milk and 
dairy products, 
egg yolk, fish 
liver oils, liver, 
oysters; formed 
in the skin by 
exposure to 

Vegetable oils, 
wheat germ, 
whole grain or 
fortified cereals, 
green leafy veg- 
etables, nuts 

May be of benefit in 
prevention of cancer 
because of its antioxi- 
dant properties which 
are associated with 
control of free radicals 
that damage DNA 
and cell membranes. 

Without vitamin D, very 
little dietary calcium 
can be absorbed. 

As an antioxidant, may 
have implications 
in the prevention of 
Alzheimer's disease, 
heart disease, breast 


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Table 11 

Essential Vitamins and Minerals— cont'd 



DRI (UL)* 

Food Sources 


Vitamin K 

Synthesis of pro- 

Men: 120ug(ND)*** 

Green vegetables 

Individuals on anticoag- 

thrombin and other 

Women: 90 ug (ND)*** 

(collards, spin- 

ulant therapy should 

clotting factors; nor- 

ach, lettuce, kale, 

monitor vitamin K 

mal blood coagulation 

broccoli, brussels 
sprouts, cab- 
bage), plant oils, 
and margarine 


Vitamin C 

Formation of collagen 

Men: 90 mg (2,000 mg) 

Citrus fruits, 

As an antioxidant, may 

in connective tissues; 

Women: 75 mg (2,000 mg) 


have implications 

a powerful antioxi- 

potatoes, green 

in the prevention 

dant; facilitates iron 

leafy vegetables, 

of cancer, cataracts, 

absorption; aids in the 


heart disease. It may 

release of epinephrine 

stimulate the immune 

from the adrenal 

system to fight various 

glands during stress 

types of infection. 

Vitamin B 2 (thiamine) 

Essential for normal 

Men: 1.2mg(ND)*** 

Whole grains, leg- 

Large doses may 

functioning of nerv- 

Women: 1 . 1 mg (ND)*** 

umes, nuts, egg 

improve mental 

ous tissue; coenzyme 

yolk, meat, green 

performance in people 

in carbohydrate 

leafy vegetables 

with Alzheimer's 



Vitamin B 2 

Coenzyme in the me- 

Men: 1.3mg(ND)*** 

Meat, dairy prod- 

May help in the preven- 


tabolism of protein 

Women: 1 . 1 mg (ND)*** 

ucts, whole or 

tion of cataracts; high- 

and carbohydrate for 

enriched grains, 

dose therapy may be 


legumes, nuts 

effective in migraine 
prophylaxis (Schoenen 
etal, 1998). 

Vitamin B 3 (niacin) 

Coenzyme in the me- 

Men: 16 mg (35 mg) 

Milk, eggs, meats, 

High doses of niacin 

tabolism of protein 

Women: 14 mg (35 mg) 

legumes, whole 

have been successful 

and carbohydrates for 

grain and 

in decreasing levels of 


cereals, nuts 

cholesterol in some 

Vitamin B 6 (pyridoxine) 

Coenzyme in the syn- 

Men and women: 1.3 mg 

Meat, fish, grains, 

May decrease depression 

thesis and catabolism 

(100 mg) 


in some individuals 

of amino acids; essen- 

After age 50: 

bananas, nuts, 

by increasing levels of 

tial for metabolism of 

Men: 1.7 mg 

white and sweet 

serotonin; deficien- 

tryptophan to niacin 

Women: 1.5 mg 


cies may contribute 
to memory problems; 
also used in the treat- 
ment of migraines 
and premenstrual 

Vitamin B 12 

Necessary in the forma- 

Men and women: 2 .4 ug 

Found in animal 

Deficiency may con- 

tion of DNA and the 


products (e.g., 

tribute to memory 

production of red 

meats, eggs, dairy 

problems. Vegetarians 

blood cells; associ- 


can get this vitamin 

ated with folic acid 

from fortified foods. 


Intrinsic factor must be 
present in the stom- 
ach for absorption of 
vitamin B 12 . 

Folic acid (folate) 

Necessary in the forma- 

Men and women: 400 ug 

Meat; green leafy 

Important in women of 

tion of DNA and the 

(1,000 ug) 


childbearing age to 

production of red 

Pregnant women: 600 ug 

beans; peas; 

prevent fetal neural 

blood cells 

fortified cereals, 
breads, rice, and 

tube defects; may con- 
tribute to prevention 
of heart disease and 
colon cancer. 

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Table 11-5 

Essential Vitamins and Minerals— cont'd 



DRI (UL)* 

Food Sources 





Necessary in the forma- 
tion of bones and 
teeth; neuron and 
muscle functioning; 
blood clotting 

Necessary in the forma- 
tion of bones and 
teeth; a component 
and ATP; helps con- 
trol acid-base balance 
in the blood 

Protein synthesis 
and carbohydrate 
metabolism; muscular 

Men and women: 1,000 mg 

(2,500 mg) 
After age 50: 
Men and women: 1,200 me 

Men and women: 700 mg 
(4,000 mg) 

Women: 320 mg (350 mg)* 

Dairy products, 
kale, broccoli, 
spinach, sardines, 
oysters, salmon 

Milk, cheese, fish, 
meat, yogurt, ice 
cream, peas, eggs 

Green vegetables, 
legumes, seafood, 
milk, nuts, meat 

Calcium has been asso- 
ciated with prevent- 
ing headaches, muscle 
cramps, osteoporosis, 
and premenstrual 
problems. Requires 
vitamin D for 

May aid in prevention of 

asthmatic attacks and 

migraine headaches. 

relaxation following 

Deficiencies may con- 

contraction; bone 

tribute to insomnia, 




Synthesis of hemoglob- 

Men: 8 mg (45 mg) 

Meat, fish, poultry, 

Iron deficiencies can 

in and myoglobin; 

Women: (45 mg) 

eggs, nuts dark 

result in headaches 

cellular oxidation 

Childbearing age: 18 mg 

green leafy 

and feeling chroni- 

Over 50: 8 mg 

vegetables, dried 

cally fatigued. 

Pregnant: 27 mg 

fruit, enriched 

Breastfeeding: 9 mg 

pasta and bread 


Aids in the synthesis of 

Men and women: 150 ug 

Iodized salt, 

Exerts strong control- 

T 3 and T 4 

(1,100 ug) 


ling influence on 
overall body 


Works with vitamin E 

Men and women: 55 ug 

Seafood, low-fat 

As an antioxidant 

to protect cellular 

(400 ug) 

meats, dairy 

combined with 

compounds from 

products, liver 

vitamin E, may have 


some anticancer 
effect. Deficiency has 
also been associated 
with depressed mood. 


Involved in synthesis 

Men: 1 1 mg (40 mg) 

Meat, seafood, 

An important source 


Women: 8 mg (40 mg) 

fortified cereals, 

for the prevention 

energy metabolism 

poultry, eggs, 

of infection and im- 

and protein synthesis; 


provement in wound 

wound healing; 


increased immune 

functioning; neces- 

sary for normal smell 

and taste sensation. 

*Dietary Reference Intakes (UL), the most recent set of dietary recommendations for adults established by the Food and 
Nutrition Board of the Institute of Medicine, © 2004. UL is the upper limit of intake considered to be safe for use by adults 
(includes total intake from food, water, and supplements). In addition to the UL, DRIs are composed of the recommended 
dietary allowance (RDA, the amount considered sufficient to meet the requirements of 97 to 98 percent of all healthy indi- 
viduals) and the adequate intake (AI, the amount considered sufficient where no RDA has been established). 

**UL for magnesium applies only to intakes from dietary supplements, excluding intakes from food and water. 

***ND, not determined. 

Source: Adapted from National Academy of Sciences (2004). 

2338_Ch11_204-230.indd 217 

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• Alcoholic beverages: Individuals who choose to 
drink alcoholic beverages should do so sensibly 
and in moderation — defined as the consumption of 
up to one drink per day for women and up to two 
drinks per day for men. One drink should count as: 

12 ounces of regular beer (150 calories) 

5 ounces of wine (100 calories) 

1.5 ounces of 80-proof distilled spirits (100 


Alcohol should be avoided by individuals who are un- 
able to restrict their intake; women who are pregnant, 
may become pregnant, or are breastfeeding; and indi- 
viduals who are taking medications that may interact 
with alcohol or who have specific medical conditions. 

Chiropractic Medicine 

Chiropractic medicine is one of the most widely 
used forms of alternative healing in the United States. 
It was developed in the late 1800s by a self-taught 
healer named David Palmer. It was later reorganized 
and expanded by his son Joshua, a trained practitioner. 
Palmer's objective was to find a cure for disease and ill- 
ness that did not use drugs, but instead relied on more 
natural methods of healing (Trivieri & Anderson, 
2002). Palmer's theory behind chiropractic medicine 
was that energy flows from the brain to all parts of the 
body through the spinal cord and spinal nerves. When 
vertebrae of the spinal column become displaced, they 
may press on a nerve and interfere with the normal 
nerve transmission. Palmer named the displacement of 
these vertebrae subluxation, and he alleged that the 
way to restore normal function was to manipulate the 
vertebrae back into their normal positions. These ma- 
nipulations are called adjustments. 

Adjustments are usually performed by hand, al- 
though some chiropractors have special treatment tables 
equipped to facilitate these manipulations (Fig. 11-2). 
Other processes used to facilitate the outcome of the spi- 
nal adjustment by providing muscle relaxation include 
massage tables, application of heat or cold, and ultra- 
sound treatments. 

The chiropractor takes a medical history and per- 
forms a clinical examination, which usually includes 
x-ray films of the spine. Today's chiropractors may 
practice "straight" therapy, that is, the only therapy 
provided is that of subluxation adjustments. Mixer is 
a term applied to a chiropractor who combines adjust- 
ments with adjunct therapies, such as exercise, heat 
treatments, or massage. 

Individuals seek treatment from chiropractors for 
many types of ailments and illnesses; the most common 

FIGURE 11-2 Chiropractic adjustments. 

is back pain. In addition, chiropractors treat clients 
with headaches, neck injuries, scoliosis, carpal tunnel 
syndrome, respiratory and gastrointestinal disorders, 
menstrual difficulties, allergies, sinusitis, and certain 
sports injuries (Trivieri & Anderson, 2002). Some chi- 
ropractors are employed by professional sports teams 
as their team physicians. 

Chiropractors are licensed to practice in all 50 
states, and treatment costs are covered by government 
and most private insurance plans. They treat over 
20 million people in the United States annually (Sadock 
& Sadock, 2007). 

Therapeutic Touch and Massage 

Therapeutic Touch 

Therapeutic touch was developed in the 1970s 
by Dolores Krieger, a nurse associated with the 
New York University School of Nursing. It is based on 
the philosophy that the human body projects a field 
of energy. When this field becomes blocked, pain or 
illness occurs. Practitioners of therapeutic touch use 

2338_Ch11_204-230.indd 218 

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this method to correct the blockages, thereby reliev- 
ing the discomfort and improving health. 

Based on the premise that the energy field extends 
beyond the surface of the body, the practitioner need 
not actually touch the client's skin. The therapist's 
hands are passed over the client's body, remaining 
2 to 4 inches from the skin. The goal is to re-pattern 
the energy field by performing slow, rhythmic, sweep- 
ing hand motions over the entire body. Heat should 
be felt where the energy is blocked. The therapist 
"massages" the energy field in that area, smoothing 
it out, and thus correcting the obstruction. Thera- 
peutic touch is thought to reduce pain and anxiety 
and promote relaxation and health maintenance. It 
has proved to be useful in the treatment of chronic 
health conditions. 


Massage is the technique of manipulating the muscles 
and soft tissues of the body. Chinese physicians pre- 
scribed massage for the treatment of disease more than 
5,000 years ago. The Eastern style focuses on balancing 
the body's vital energy (qi) as it flows through pathways 
(meridians), as described earlier in the discussion of acu- 
pressure and acupuncture. The Western style of massage 
affects muscles, connective tissues (e.g., tendons and liga- 
ments), and the cardiovascular system. Swedish massage, 
which is probably the best-known Western style, uses a 
variety of gliding and kneading strokes along with deep 
circular movements and vibrations to relax the muscles, 
improve circulation, and increase mobility (Trivieri & 
Anderson, 2002). 

Massage has been shown to be beneficial in the fol- 
lowing conditions: anxiety, chronic back and neck pain, 
arthritis, sciatica, migraine headaches, muscle spasms, 
insomnia, pain of labor and delivery, stress-related dis- 
orders, and whiplash. Massage is contraindicated in 
certain conditions, such as high blood pressure, acute 
infection, osteoporosis, phlebitis, skin conditions, and 
varicose veins. It also should not be performed over 
the site of a recent injury, bruise, or burn. 

Massage therapists require specialized training in a 
program accredited by the American Massage Therapy 
Association and must pass the National Certification 
Examination for Therapeutic Massage and Bodywork. 


Yoga is thought to have developed in India some 
5,000 years ago and is attributed to an Indian physi- 
cian and Sanskrit scholar named Patanjali. The objec- 
tive of yoga is to integrate the physical, mental, and 

spiritual energies that enhance health and well-being 
(Trivieri & Anderson, 2002). Yoga has been found to 
be especially helpful in relieving stress and in im- 
proving overall physical and psychological wellness. 
Proper breathing is a major component of yoga. It is 
believed that yoga breathing — a deep, diaphragmatic 
breathing — increases oxygen to brain and body tis- 
sues, thereby easing stress and fatigue, and boosting 

Another component of yoga is meditation. Individu- 
als who practice the meditation and deep breathing as- 
sociated with yoga find that they are able to achieve a 
profound feeling of relaxation (Fig. 11-3). 

The most familiar type of yoga practiced in West- 
ern countries is hatha yoga. Hatha yoga uses body 
postures, along with the meditation and breathing 
exercises, to achieve a balanced, disciplined work- 
out that releases muscle tension; tones the internal 
organs; and energizes the mind, body, and spirit, to 
allow natural healing to occur. The complete rou- 
tine of poses is designed to work all parts of the 
body — stretching and toning muscles, and keeping 
joints flexible. Studies have shown that yoga has 
provided beneficial effects to some individuals with 
back pain, stress, migraine, insomnia, high blood 
pressure, rapid heart rates, and limited mobility 
(Sadock & Sadock, 2007; Steinberg, 2002; Trivieri 
& Anderson, 2002). 

Pet Therapy 

The therapeutic value of pets is no longer just the- 
ory. Evidence has shown that animals can directly 

FIGURE 11-3 Achieving relaxation through the practice 
of yoga. 

2338_Ch11_204-230.indd 219 

8/31/10 5:59:52 PM 


influence a person's mental and physical well-being. 
Many pet therapy programs have been established 
across the country and the numbers are increasing 

Several studies have provided information about the 
positive results of human interaction with pets. Some 
of these include the following: 

1 . Petting a dog or cat has been shown to lower blood 
pressure. In one study, volunteers experienced a 
7.1 -mm Hg drop in systolic and an 8.1 -mm Hg de- 
crease in diastolic blood pressure when they talked 
to and petted their dogs, as opposed to reading 
aloud or resting quietly (Whitaker, 2000). 

2 . Bringing a pet into a nursing home or other institu- 
tion for the elderly has been shown to enhance a cli- 
ent's mood and social interaction (Godenne, 2001). 
Another study revealed that animal-assisted therapy 
with nursing home residents significantly reduced 
loneliness for those in the study group (Banks & 
Banks, 2002). 

3 . One study of 96 patients who had been admitted 
to a coronary care unit for heart attack or angina 
revealed that in the year following hospitalization, 
the mortality rate among those who did not own 
pets was 22 percent higher than among pet owners 
(Whitaker, 2000). 

4. Individuals with AIDS who have pets are less likely 
to suffer from depression than people with AIDS 
who do not own pets (Siegel et al, 1999). 

Some researchers believe that animals actually may 
retard the aging process among those who live alone 
(Fig. 11-4). Loneliness often results in premature 
death, and having a pet mitigates the effects of loneli- 
ness and isolation. Whitaker (2000) suggests: 

Though owning a pet doesn't make you immune to 
illness, pet owners are, on the whole, healthier than 
those who don't own pets. Study after study shows that 
people with pets have fewer minor health problems, 
require fewer visits to the doctor and less medication, 
and have fewer risk factors for heart disease, such as 
high blood pressure or cholesterol levels, (p. 7) 

It may never be known precisely why animals affect 
humans the way they do, but for those who have pets 
to love, the therapeutic benefits come as no surprise. 
Pets provide unconditional, nonjudgmental love and 
affection, which can be the perfect antidote for a de- 
pressed mood or a stressful situation. The role of ani- 
mals in the human healing process still requires more 
research, but its validity is now widely accepted in both 
the medical and lay communities. 

FIGURE 11-4 Healthy aging with a pet. 


Individual Psychotherapies 

Individual psychotherapy takes place on a one-to-one 
basis between a client and a therapist. Mental health 
professionals who usually perform individual psycho- 
therapy include advanced practice registered nurses, 
psychiatric social workers, psychiatrists, psychologists, 
and licensed mental health counselors. An agreement 
is established and, within a therapeutic environment, 
the therapist assists the client to overcome behavioral 
symptoms or resolve interpersonal problems. Several 
models of individual psychotherapy are discussed in 
this section. 


Psychoanalysis is considered by many to be the foun- 
dation for individual psychotherapy. It was originated 
by Freud in the early 20th century (see Chapter 2). In 

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psychoanalysis, a major goal is for the client to gain 
insight and understanding about current relationships 
and behavior patterns by confronting unconscious con- 
flicts that surface in the transference relationship with 
the analyst. Psychoanalysis is a lengthy and costly type 
of treatment. Some of the techniques used in psychoa- 
nalysis are described in the following subsections.* 

Free Association 

In free association, the client is allowed to say whatever 
comes to mind in response to a word that is given by the 
therapist. For example, the therapist might say "moth- 
er" or "blue," and the client would give a response, also 
typically one word, to each of these words. The therapist 
then looks for a theme or pattern to the client's respons- 
es. If the client responds "evil" to the word "mother" or 
"dead" to the word "blue," the therapist might pick up 
one potential theme, but if the client responds "kind" 
and "true" to the words "mother" and "blue," the thera- 
pist might hear a completely different theme. The theme 
may give the therapist an idea of the cause of the client's 
emotional disturbance. 

Dream Analysis 

Freudians believe that behavior is rooted in the uncon- 
scious and that dreams are a manifestation of the trou- 
bles people repress. Psychoanalysts believe that dreams 
truly are the mirror to the unconscious. Monitoring 
and interpreting dreams is an important technique of 
psychoanalysis. The client is asked to keep a "dream 
log" by writing in a notebook as much as he or she can 
remember of both pleasant and particularly disturbing 
dreams. The dreams are then interpreted in much the 
same way as for free association. Significant people or 
situations in the dreams are explored with the client, 
and possible meanings are offered by the therapist. 


Hypnotherapy is sometimes used in psychoanalysis as 
a tool for unlocking the unconscious or for searching 
farther into "past life regression." Hypnosis is very deep 
relaxation during which the therapist, who has been 
trained in techniques of trance formation, asks cer- 
tain questions of the client. Guided imagery also may 
be used to help the client envision the situation in an 
effort to find the cause of the problem. At the close of 

This section reprinted with permission from Neeb, K. (2006). 
Fundamentals of mental health nursing (3rd ed.). Philadelphia: 
F.A. Davis. 

the session, while the individual is still in the trance 
state, the therapist may offer some posthypnotic sug- 
gestions. These typically include positive, affirming 
statements for the client to think about and to assist 
the client with changes in behavior he or she wants to 


Sadock and Sadock (2007) define catharsis as "the 
expression of ideas, thoughts, and suppressed mate- 
rial that is accompanied by an emotional response 
that produces a state of relief in the patient" (p. 937). 
Catharsis is used in psychoanalysis to allow the client 
to purge the repressed mental contents from the psy- 
che. Maladaptive symptoms may be resolved by bring- 
ing unconscious thoughts and feelings into conscious- 
ness. Sometimes the individual not only may recall 
the painful experience, but also may actually relive it, 
accompanied by the feelings and emotions associated 
with the event. This process is called abreaction. 

Interpersonal Psychotherapy 

Interpersonal psychotherapy (IPT) is a time-limited 
therapy that was developed for the treatment of major 
depression. Time-limited psychotherapies (also called 
brief psychotherapy) have a specific focus, identified 
goals, and a limited number of sessions. Theoretical ap- 
proaches include psychoanalytic, psychodynamic, inter- 
personal, and integrative. 

IPT is based on the concepts of Harry Stack 
Sullivan, assuming that the symptoms and social dys- 
function associated with depression (and other psy- 
chiatric disorders) are correlated with difficulties in 
interpersonal relations. The overall goal of IPT is 
improvement in current interpersonal skills (Sadock 
& Sadock, 2007). Sessions generally occur weekly for 
about 12 to 16 weeks. 

In the initial sessions, the therapist gathers infor- 
mation by taking a psychiatric history, identifying the 
major problem, establishing a diagnosis, and, together 
with the client, outlining the goals of therapy. Apian of 
action for the remaining therapy sessions defines spe- 
cific interventions targeted at resolving the identified 
problem. Markowitz (2008) states: 

Sessions open with the question: "How have things 
been since we last met?" This focuses the patient on 
the recent interpersonal events and recent mood, which 
the therapist helps the patient to link. Therapists take 
an active, nonneutral, supportive, and hopeful stance to 
counter the depressed patient's pessimism. They elicit 
and emphasize the options that exist for change in the 

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patient's life, options that the depressive episode may 
have kept the patient from seeing or exploring frilly. 
Understanding the situation does not suffice: therapists 
stress the need for patients to test these options in 
order to improve their lives and simultaneously treat 
their depressive episodes, (p. 1194) 

IPT as monotherapy has been used successfully with 
mild to moderate major depressive disorder. Studies 
have shown that in clients with severe or recurrent 
major depressive disorder, a combination of psycho- 
therapy and pharmacotherapy is better than either 
alone (Karasu, Gelenberg, Merriam, & Wang, 2006). 
Trials are currently underway to study the efficacy of 
IPT with social phobia, bipolar disorder, post- traumatic 
stress disorder, borderline personality disorder, panic 
disorder, and bulimia. Clinical trials failed to dem- 
onstrate efficacy of IPT with substance use disorders 
(Markowitz, 2008). 

Reality Therapy 

Reality therapy was developed in the mid-1960s by 
the American psychiatrist William Glasser. The ther- 
apy is based on control theory and suggests that all 
individuals are responsible for what they choose to do. 
It includes the principle that human beings are born 
with the following five basic needs: 

• Power (includes achievement, competence, and ac- 

• Belonging (includes social groups, as well as families 
and loved ones) 

• Freedom (includes independence and personal au- 

• Fun (includes enjoyment and pleasure) 

• Survival (includes physiological needs, such as food, 
shelter, sexual expression) 

Personality development is viewed as an attempt 
to fulfill these five basic needs. Individuals choose be- 
haviors and subsequently discover whether the chosen 
behaviors are effective or ineffective in satisfying those 
needs. Glasser and Wubbolding (1995) state, "When 
[individuals] habitually fail to fulfill their needs effec- 
tively, they develop a failure identity characterized by 
ineffective or out-of-control behaviors" (p. 300). 

In reality therapy, emphasis is on the present — the 
here and now. Past behavior is addressed only as it 
impacts present choices or future behavior. A primary 
function of the therapist is to assist the client in deal- 
ing with getting needs met in the present. The thera- 
pist helps the client identify needs that are not being 
met, correlate the unmet needs to current ineffective 

behaviors, and make conscious choices to change to 
more effective patterns of behavior in an effort to sat- 
isfy basic needs. 

In reality therapy, psychopathology is viewed in terms 
of ineffective behaviors. Diagnoses and labels (e.g., neu- 
rotic or dysfunctional) are perceived as stereotypical 
and not particularly useful. The concept of responsibil- 
ity is emphasized. Accepting responsibility for one's own 
behavior is equated with mental health. An individual who 
behaves responsibly is able to fulfill his or her basic needs 
without interfering with others' attempts at need fulfill- 
ment. An important part of the therapist's role is serving as 
a positive role model for responsible behavior. 

Glasser and Wubbolding (1995) state: 

Through the skillful use of reality therapy, it is pos- 
sible to help a person evaluate whether behavioral 
change is desirable and possible and whether adjust- 
ing to the demands of the "real world" would be ap- 
propriate and satisfying. If clients decide that change 
is beneficial to them, they are helped to make better 
choices designed to maintain or increase their need 
fulfillment, (p. 294) 

Reality therapy can be very self-empowering for a 
client. Hope is instilled when therapy does not dwell 
on past failures, and the client is able to look forward 
toward a change in behavior. Reality therapy promotes 
the conviction that although an individual is a product 
of the past, he or she need not continue as its victim. 

Relaxation Therapy 

Stress is a part of our everyday lives. It can be positive 
or negative, but it cannot be eliminated. Keeping stress 
at a manageable level is a lifelong process. 

Individuals under stress respond with a physiologi- 
cal arousal that can be dangerous over long periods. In- 
deed, the stress response has been shown to be a major 
contributor, either directly or indirectly, to coronary 
heart disease, cancer, lung ailments, accidental injuries, 
cirrhosis of the liver, and suicide — six of the leading 
causes of death in the United States. 

Relaxation therapy is an effective means of reducing 
the stress response in some individuals. The degree of 
anxiety that an individual experiences in response to 
stress is related to certain predisposing factors, such as 
characteristics of temperament with which he or she 
was born, past experiences resulting in learned patterns 
of responding, and existing conditions, such as health 
status, coping strategies, and adequate support systems. 

Deep relaxation can counteract the physiological 
and behavioral manifestations of stress. Various meth- 
ods of relaxation are described. 

2338_Ch11_204-230.indd 222 

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Deep-Breathing Exercises 

Tension is released when the lungs are allowed to 
breathe in as much oxygen as possible. Deep-breathing 
exercises involve inhaling slowly and deeply through 
the nose, holding the breath for a few seconds, and 
then exhaling slowly through the mouth, pursing the 
lips as if trying to whistle. 

Progressive Relaxation 

This method of deep-muscle relaxation is based 
on the premise that the body responds to anxiety- 
provoking thoughts and events with muscle tension. 
Each muscle group is tensed for 5 to 7 seconds and 
then relaxed for 20 to 30 seconds, during which 
time the individual concentrates on the difference 
in sensations between the two conditions. Soft, slow 
background music may facilitate relaxation. A modi- 
fied version of this technique (called passive progres- 
sive relaxation) involves relaxation of the muscles by 
concentrating on the feeling of relaxation within the 
muscle, rather than the actual tensing and relaxing 
of the muscle. 


The goal of meditation is to gain mastery over at- 
tention. It brings on a special state of consciousness 
as attention is concentrated solely on one thought or 
object. During meditation, as the individual becomes 
totally preoccupied with the selected focus, the res- 
piration rate, heart rate, and blood pressure decrease. 
The overall metabolism declines and the need for 
oxygen consumption is reduced. 

Mental Imagery 

Mental imagery uses the imagination in an effort to 
reduce the body's response to stress. The frame of 
reference is very personal, based on what each indi- 
vidual considers to be a relaxing environment. The 
relaxing scenario is most useful when recorded and 
played back at a time when the individual wishes to 
achieve relaxation. 


Biofeedback is the use of instrumentation to be- 
come aware of processes in the body that usually go 
unnoticed and to help bring them under voluntary 

control. Biological conditions, such as muscle ten- 
sion, skin surface temperature, blood pressure, and 
heart rate, are monitored by the biofeedback equip- 
ment. With special training, the individual learns to 
use relaxation and voluntary control to modify the 
biological condition, in turn indicating a modifica- 
tion of the autonomic function it represents. Bio- 
feedback is often used together with other relaxa- 
tion techniques such as deep breathing, progressive 
relaxation, and mental imagery. 

Assertiveness Training 

Assertive behavior helps individuals feel better about 
themselves by encouraging them to stand up for their 
own basic human rights, which apply to all individu- 
als. However, along with rights come an equal number 
of responsibilities, and part of being assertive includes 
living up to these responsibilities. 

Assertive behavior increases self-esteem and the 
ability to develop satisfying interpersonal relation- 
ships. This is accomplished through honesty, direct- 
ness, appropriateness, and respecting one's own rights, 
as well as the rights of others. 

Individuals develop patterns of responding in various 
ways, such as through role modeling, by receiving posi- 
tive or negative reinforcement, or by conscious choice. 
These patterns can take the form of nonassertiveness, 
assertiveness, aggressiveness, or passive- aggressiveness. 

Nonassertive individuals seek to please others at 
the expense of denying their own basic human rights. 
Assertive individuals stand up for their own rights while 
protecting the rights of others. Those who respond 
aggressively defend their own rights by violating the 
basic rights of others. Individuals who respond in 
a passive-aggressive manner defend their own rights 
by expressing resistance to social and occupational 

Some important behavioral considerations of as- 
sertive behavior include eye contact, body posture, 
personal distance, physical contact, gestures, facial 
expression, voice, fluency, timing, listening, thoughts, 
and content. Various techniques have been developed 
to assist individuals in the process of becoming more 
assertive. Some of these include the following: 

• Standing up for one's basic human rights: 


: T have the right to express my opinion." 

2338_Ch11_204-230.indd 223 

8/31/10 5:59:54 PM 


• Assuming responsibility for one's own state- 


"I don h want to go out with you tonight," instead of "I 
can h go out with you tonight." The latter implies a lack 
of power or ability. 

• Responding as a "broken record": Persistently 
repeating in a calm voice what is wanted. 


Telephone salesperson: "I want to help you save 
money by changing long-distance services." 
Assertive response: "I don't want to change my long- 
distance service." 

Telephone salesperson: "I can't believe you don't 
want to save money!" 

Assertive response: "I don't want to change my long- 
distance service." 

• Agreeing assertively: Assertively accepting nega- 
tive aspects about oneself. Admitting when an error 
has been made. 


Ms. Jones: "You sure let that meeting get out of 
hand. What a waste of time." 

Ms. Smith: "Yes, I didn't do a very good job of con- 
ducting the meeting today." 

• Inquiring assertively: Seeking additional informa- 
tion about critical statements. 


Male board member: "You made a real fool of 

yourself at the board meeting last night." 

Female board member: "Oh, really? Just what about 

my behavior offended you?" 

Male board member: "You were so damned 


Female board member: "Were you offended that I 

spoke up for my beliefs, or was it because my beliefs 

are in direct opposition to yours?" 

• Shifting from content to process: Changing the 
focus of the communication from discussing the 
topic at hand to analyzing what is actually going on 
in the interaction. 


Wife: "Would you please call me if you will be late 

for dinner?" 

Husband: "Why don't you just get off my back! I 

always have to account for every minute of my time 

with you!" 

Wife: "Sounds to me like we need to discuss some 

other things here. What are you really angry 


• Clouding/fogging: Concurring with the critic's 
argument without becoming defensive and without 
agreeing to change. 


Nurse No. 1: "You make so many mistakes. I don't 
know how you ever got this job!" 
Nurse No. 2: "You're right. I have made some mis- 
takes since I started this job." 

• Defusing: Putting off farther discussion with an 
angry individual until he or she is calmer. 


"You are very angry right now. I don't want to dis- 
cuss this matter with you while you are so upset. I will 
discuss it with you in my office at 3 o'clock this 

• Delaying assertively: Putting off farther discus- 
sion with another individual until one is calmer. 


"That's a very challenging position you have taken, 
Mr. Brown. I'll need time to give it some thought. I'll 
call you later this afternoon." 

• Responding assertively with irony: 


Man: "I bet you're one of them so-called 'women's 

libbers,' aren't you?" 

Woman: "Why yes, I am. Thank you for noticing." 

Cognitive Therapy 

Cognitive therapy, developed by Aaron Beck, is com- 
monly used in the treatment of mood disorders. In 
cognitive therapy, the individual is taught to control 

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thought distortions that are considered to be a factor in 
the development and maintenance of mood disorders. 
In the cognitive model, depression is characterized by 
a triad of negative distortions related to expectations 
of the environment, self, and future. The environment 
and activities within it are viewed as unsatisfying, the 
self is unrealistically devalued, and the future is per- 
ceived as hopeless. In the same model, mania is char- 
acterized by a positive cognitive triad — the self is seen 
as highly valued and powerful, experiences within the 
environment are viewed as overly positive, and the fu- 
ture is seen as one of unlimited opportunity. 

The general goals in cognitive therapy are to obtain 
symptom relief as quickly as possible, to assist the client 
in identifying dysfunctional patterns of thinking and 
behaving, and to guide the client to evidence and logic 
that effectively tests the validity of the dysfunctional 
thinking. Therapy focuses on changing "automatic 
thoughts" that occur spontaneously and contribute to 
the distorted affect. Examples of "automatic thoughts" 
in depression include the following: 

• Personalizing: "I'm the only one who failed." 

• All or nothing: "I'm a complete failure." 

• Mind reading: "He thinks I'm foolish." 

• Discounting positives: "The other questions were 
so easy. Any dummy could have gotten them right." 

Examples of "automatic thoughts" in mania include 
the following: 

• Personalizing: "She's this happy only when she's 
with me." 

• All or nothing: "Everything I do is great." 

• Mind reading: "She thinks I'm wonderful." 

• Discounting negatives: "None of those mistakes 
are really important." 

The client is asked to describe evidence that both 
supports and disputes the automatic thought. The 
logic underlying the inferences is then reviewed with 
the client. Another technique involves evaluating what 
would most likely happen if the client's automatic 
thoughts were true. Implications of consequences are 
then discussed. 

Clients should not become discouraged if one tech- 
nique seems not to be working. There is no single 
technique that works with all clients. He or she should 
be reassured that there are a number of techniques 
that may be used, and both therapist and client may 
explore these possibilities. Cognitive therapy has been 
shown to be an effective treatment for mood disorders, 
particularly in conjunction with psychopharmacologi- 
cal intervention. 


Alternative medicine includes those practices that 
differ from the usual traditional ones in the treat- 
ment of disease. 

Complementary therapies are those that work in part- 
nership with traditional medical practice. 
Complementary therapies help the practitioner view 
the client in a holistic manner. 
Most complementary therapies consider the mind 
and body connection and strive to enhance the 
body's own natural healing powers. 

I The National Center for Complementary and Al- 
ternative Medicine of the National Institutes of 
Health has established a list of complementary and 
alternative therapies to be used in practice and for 
investigative purposes. 

More than $27 billion a year is spent on alternative 
medical therapies in the United States. 
Many people are seeking a return to herbal remedies. 
Because they do not require approval by the U.S. 
Food and Drug Administration, their use should be 
approached cautiously and responsibly. 
With acupressure and acupuncture, pressure is ap- 
plied (or small needles are inserted) into points 
along specific pathways of the body called merid- 
ians. This is done in an effort to dissolve obstruc- 
tions in the flow of healing energy and restore the 
body to a healthier functioning. 
The value of nutrition in the healing process has 
long been underrated. Nutrition is, in part, a pre- 
ventive science. The U.S. Department of Agri- 
culture and the U.S. Department of Health and 
Human Services have collaborated on a set of 
guidelines to help individuals understand what 
types of foods to eat and the healthy lifestyle they 
need to pursue in order to promote health and 
prevent disease. 

J The theory behind chiropractic medicine is that 
energy flows from the brain to all parts of the body 
through the spinal cord and spinal nerves. When 
vertebrae become displaced, there is interference 
with normal nerve transmission. Chiropractic ad- 
justments manipulate the displacements back into 
position, thereby restoring normal functioning. 
Therapeutic touch promotes relaxation and re- 
patterns the body's energy field by unblocking 
obstructions. Massage relaxes muscles, improves 
circulation, and increases mobility. 
Yoga serves to integrate the physical, mental, and 
spiritual energies that enhance health and well- 
being. Body postures, breathing exercises, and 

2338_Ch11_204-230.indd 225 

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meditation combine to achieve a balanced workout 
and allow natural healing to occur. 
The therapeutic benefits of pet ownership are widely 
accepted. The role of animals in the human healing 
process still requires more research, but its validity 
is now widely accepted in both the medical and lay 

Nurses must be familiar with these therapies, as more 
and more clients seek out the healing properties of 
alternative and complementary care strategies. 
Psychosocial therapies are the tools of practitioners 
who work in psychiatry. 

Selected psychosocial therapies were discussed in 
this chapter: psychoanalysis, interpersonal psycho- 
therapy, reality therapy, relaxation therapy, assert- 
iveness training, and cognitive therapy. Advanced 
practice psychiatric nurses may use some of these 
therapies in their practices. 

It is important for all nurses to understand the con- 
cepts associated with these therapies in order to be 
effective members of the treatment team. 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 


1. Which of the following herbs is thought to be helpful in cases of nervousness, anxiety, and/or 
insomnia? Select all that apply. 

a. Chamomile 

b. Echinacea 

c. Kava-Kava 

d. Ginseng 

e. Valerian 

f. Hops 

2. Which of the following food groups do the USDA/USDHHS food guidelines recommend using in 
moderation? Select all that apply. 

a. Refined carbohydrates 

b. Fats 

c. Milk and milk products 

d. Sodium chloride 

e. Whole grains 

3. Which of the following herbs is thought to be helpful in relieving menstrual cramping? Select all 
that apply. 

a. Feverfew 

b. Ginger 

c. Chamomile 

d. Black cohosh 

4. With which of the following conditions should massage not be performed? Select all that apply. 

a. High blood pressure 

b. Neck pain 

c. Arthritis 

d. Phlebitis 

e. Osteoporosis 

5. Which of the following applies to vitamin C? 

a. Coenzyme in protein metabolism; found in meat and dairy products 

b. Necessary in formation of DNA; found in beans and other legumes 

c. A powerful antioxidant; found in tomatoes and strawberries 

d. Necessary for blood clotting; found in whole grains and bananas 

6. Which of the following applies to calcium? 

a. Coenzyme in carbohydrate metabolism; found in whole grains and citrus fruits 

b. Facilitates iron absorption; found in vegetable oils and liver 

c. Prevents night blindness; found in egg yolk and cantaloupe 

d. Important for nerve and muscle functioning; found in dairy products and oysters 

7. Subluxation is a term used by chiropractic medicine to describe: 

a. displacement of vertebrae in the spine. 

b. adjustment of displaced vertebrae in the spine. 

c. interference with the flow of energy from the brain. 

d. pathways along which energy flows throughout the body. 

2338_Ch11_204-230.indd 227 

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8. Nancy has been diagnosed with Dysthymic Disorder. The physician has just prescribed fluoxetine 
20 mg/day Nancy tells the nurse that she has been taking St. John's wort, but still feels depressed. 
Which of the following is the appropriate response by the nurse? 

a. "St. John's wort is not effective for depression." 

b. "Do not take fluoxetine and St. John's wort together." 

c. "You probably just need to increase your dose of St. John's wort." 

d. "Go ahead and take the St. John's wort with the fluoxetine. Maybe both of them together will 
be more helpful." 

9. In reality therapy, a primary function of the therapist is: 

a. assisting the client to deal with getting current needs fulfilled. 

b. hypnotizing the client to delve into the unconscious. 

c. analyzing the possible meanings behind the client's dreams. 

d. taking a psychiatric history and establishing a diagnosis. 

10. A fellow worker often borrows small amounts of money from you with the promise that she will 
pay you back "tomorrow." She currently owes you $1 5.00, and has not yet paid back any that she 
has borrowed. She asks if she can borrow a couple of dollars for lunch. Which of the following is a 
nonassertive response? 

a. "I've decided not to loan you any more money until you pay me back what you already 

b. "I'm so sorry. I only have enough to pay for my own lunch today." 

c. "Get a life, will you? I'm tired of you sponging off me all the time!" 

d. "Sure, here's two dollars." Then to the other workers in the office: "Be sure you never lend 
Cindy any money. She never pays her debts. I'd be sure never to go to lunch with her 

if I were you!" 

11. Nancy's new in-laws came to dinner for the first time. When Nancy's mother-in-law left some 
food on her plate, Nancy thought, "I must be a lousy cook!" This is an example of which type of 
"automatic thought"? 

a. All or nothing 

b. Discounting positives 

c. Catastrophic thinking 

d. Personalizing 



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American Botanical Council. 
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Council of Acupuncture and Oriental Medicine Associations 
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medicine. Retrieved April 22, 2009 from http://www.acucouncil 

Council of Acupuncture and Oriental Medicine Associations 
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DeSantis, L. (2009). Alternative and complementary healing 
practices. In J.T. Catalano (Ed.), Nursing Now! Todays issues, 
tomorrows trends (5th ed.). Philadelphia: F.A. Davis. 

Glasser, W., & Wubbolding, R.E. (1995). Reality therapy. In 
R.J. Corsini & D. Wedding (Eds.), Current psychotherapies 
(5th ed.). Itasca, IL: F.E. Peacock. 

Godenne, G. (2001). The role of pets in nursing homes . . . and 
psychotherapy. The Maryland Psychiatrist, 27(3), 5-6. 

Holt, G.A., & Kouzi, S. (2002). Herbs through the ages. In M.A. 
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Karasu, T.B., Gelenberg, A., Merriam, A., & Wang, P. (2006). Prac- 
tice guideline for the treatment of patients with major depressive 
disorder. In The American Psychiatric Association practice guidelines 

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for the treatment of psychiatric disorders, compendium 2006. 
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Evidence-based applications (4th ed.). Philadelphia: FA. Davis. 

Markowitz, J.C. (2008). Interpersonal psychotherapy. In R.E. Hales, 
S.C. Yudofsky, & G.O. Gabbard (Eds.), The American Psychiatric 
Publishing textbook of psychiatry (5th ed.). Washington, DC: 
American Psychiatric Publishing. 

National Academy of Sciences. (2004). Dietary reference intakes 
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National Center for Complementary and Alternative Medicine 
(NCCAM). (2007). CAM basics. NCCAM Publication No. D347. 
Bethesda, MD: NCCAM. 

National Center for Complementary and Alternative Medicine 
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National Institutes of Health (NIH). (2008). The use of complemen- 
tary and alternative medicine in the United States. Bethesda, 

Neeb, K. (2006). Fundamentals of mental health nursing (3rd ed.), 
Philadelphia: FA Davis. 

PDRfor herbal medicines (4th ed.). (2007). Montvale, NJ: 
Thomson PDR. 

Pranthikanti, S. (2007). Ayurvedic treatments. In J.H. Lake & 
D. Spiegel (Eds.), Complementary and alternative treatments 
in mental health care. Washington, DC: American Psychiatric 

Sadock, B.J., & Sadock, VA. (2007). Synopsis of psychiatry: Behavioral 
sciences/clinical psychiatry (10th ed.). Philadelphia: Lippincott 
Williams & Wilkins. 

Schoenen, J., Jacquy, J., & Lenaerts, M. (1998, February). Effective- 
ness of high-dose riboflavin in migraine prophylaxis: 
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2338_Ch11_204-230.indd 230 8/31/10 6:00:03 PM 

Unit Three 

Care of Clients 
With Psychiatric 


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2338_Ch12_231-265.indd 232 

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H A P T E R 

Delirium, Dementia, 
and Amnestic Disorders 














primary dementia 

secondary dementia 



delirium dementia 


After reading this chapter, the student will be able to: 

1. Define and differentiate among delirium, 
dementia, and amnestic disorders. 

2. Discuss etiological implications associat- 
ed with delirium, dementia, and amnestic 

3. Describe clinical symptoms and use the 
information to assess clients with deliri- 
um, dementia, and amnestic disorders. 

4. Identify nursing diagnoses common to 
clients with delirium, dementia, and 

amnestic disorders, and select appropri- 
ate nursing interventions for each. 

5. Identify topics for client and family teach- 
ing relevant to cognitive disorders. 

6. Discuss criteria for evaluating nursing 
care of clients with delirium, dementia, 
and amnestic disorders. 

7. Describe various treatment modalities 
relevant to care of clients with delirium, 
dementia, and amnestic disorders. 


2338_Ch12_231-265.indd 233 

8/31/10 6:00:19 PM 


Please read the chapter and answer the following questions. 



An alteration in which neurotransmitter 
is most closely associated with the etiol- 
ogy of Alzheimer's disease? 
How does vascular dementia differ from 
Alzheimer's disease? 

3. What is pseudodementia? 

4. What is the primary concern for nurses 
working with clients with cognitive 


Cognitive disorders include those in which a clini- 
cally significant deficit in cognition or memory 
exists, representing a significant change from a 
previous level of functioning. The Diagnostic and 
Statistical Manual of Mental Disorders, Fourth Edition, 
Text Revision (DSM-IV-TR) (American Psychiatric 
Association [APA], 2000) describes the etiology of 
these disorders as a general medical condition, a sub- 
stance, or a combination of these factors. 

These disorders were previously identified as organic 
mental syndromes and disorders. With the publication of 
the DSM-IV (APA, 1994), the name was changed to 
prevent the implication that nonorganic mental disor- 
ders do not have a biological basis. 

This chapter presents etiological implications, clini- 
cal symptoms, and nursing interventions for care of 
clients with delirium, dementia, and amnestic disor- 
ders. The objective is to provide these individuals with 
the dignity and quality of life they deserve, while offer- 
ing guidance and support to their families or primary 


Clinical Findings and Course 

A delirium is characterized by a disturbance of con- 
sciousness and a change in cognition that develop 
rapidly over a short period (APA, 2000). Symptoms 
of delirium include difficulty sustaining and shifting 
attention. The person is extremely distractible and 
must be repeatedly reminded to focus attention. Dis- 
organized thinking prevails and is reflected by speech 
that is rambling, irrelevant, pressured, and incoherent 
and that unpredictably switches from subject to sub- 
ject. Reasoning ability and goal-directed behavior are 


impaired. Disorientation to time and place is com- 
mon, and impairment of recent memory is invariably 
evident. Misperceptions of the environment, includ- 
ing illusions and hallucinations, prevail. 

Level of consciousness is often affected, with a dis- 
turbance in the sleep-wake cycle. The state of aware- 
ness may range from that of hypervigilance (heightened 
awareness to environmental stimuli) to stupor or semi- 
coma. Sleep may fluctuate between hypersomnolence 
(excessive sleepiness) and insomnia. Vivid dreams and 
nightmares are common. 

Psychomotor activity may fluctuate between agitat- 
ed, purposeless movements (e.g., restlessness, hyperac- 
tivity, striking out at nonexistent objects) and a vegeta- 
tive state resembling catatonic stupor. Various forms of 
tremor are frequently present. 

Emotional instability may be manifested by fear, 
anxiety, depression, irritability, anger, euphoria, or 
apathy. These various emotions may be evidenced by 
crying, calls for help, cursing, muttering, moaning, 
acts of self-destruction, fearful attempts to flee, or 
attacks on others who are falsely viewed as threaten- 
ing. Autonomic manifestations, such as tachycardia, 
sweating, flushed face, dilated pupils, and elevated 
blood pressure, are common. 

The symptoms of delirium usually begin quite 
abruptly (e.g., following a head injury or seizure). At 



A mental state characterized by a disturbance of 
cognition, which is manifested by confusion, excite- 
ment disorientation, and a clouding of conscious- 
ness. Hallucinations and illusions are common. 

2338_Ch12_231-265.indd 234 

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other times, they may be preceded by several hours or 
days of prodromal symptoms (e.g., restlessness, diffi- 
culty thinking clearly, insomnia or hypersomnolence, 
nightmares). The slower onset is more common if 
the underlying cause is systemic illness or metabolic 

The duration of delirium is usually brief (e.g., 1 week; 
rarely more than 1 month), and, upon recovery from 
the underlying determinant, symptoms usually dimin- 
ish over a 3- to 7-day period, but in some instances 
may take as long as 2 weeks (Sadock & Sadock, 2007). 
The age of the client and duration of the delirium in- 
fluence the rate of symptom resolution. Delirium may 
transition into a more permanent cognitive disorder 
(e.g., dementia) and is associated with a high mortality 
rate (Bourgeois, Seaman, & Sends, 2008). 

Etiological Implications 

The DSM-IV-TR (APA, 2000) differentiates between 
the disorders of delirium by their etiology, although 
they share a common symptom presentation. Catego- 
ries of delirium include the following: 

• Delirium due to a general medical condition 

• Substance-induced delirium 

• Substance-intoxication delirium 

• Substance-withdrawal delirium 

• Delirium due to multiple etiologies 

Delirium Due to a General Medical 

In delirium due to a general medical condition, evi- 
dence must exist (from history, physical examination, 
or laboratory findings) to show that the symptoms of 
delirium are a direct result of the physiological conse- 
quences of a general medical condition (APA, 2000). 
Such conditions include systemic infections, metabolic 
disorders (e.g., hypoxia, hypercarbia, hypoglycemia), 
fluid or electrolyte imbalances, hepatic or renal dis- 
ease, thiamine deficiency, postoperative states, hyper- 
tensive encephalopathy, postictal states, sequelae of 
head trauma, and others (APA, 2000). 

Substance-Induced Delirium 

This disorder is characterized by the symptoms of 
delirium that are attributed to medication side effects 
or exposure to a toxin. The DSM-IV-TR (APA, 2000) 
lists the following examples of medications that have 
been reported to result in substance-induced delirium: 

anesthetics, analgesics, antiasthmatic agents, anticon- 
vulsants, antihistamines, antihypertensive and cardio- 
vascular medications, antimicrobials, antiparkinsonian 
drugs, corticosteroids, gastrointestinal medications, 
histamine H 2 -receptor antagonists (e.g., cimetidine), 
immunosuppressive agents, lithium, muscle relaxants, 
and psychotropic medications with anticholinergic side 
effects. Toxins reported to cause delirium include or- 
ganophosphate (anticholinesterase), insecticides, car- 
bon monoxide, and volatile substances such as fuel or 
organic solvents. 

Substance-Intoxication Delirium 

With this disorder, the symptoms of delirium may arise 
within minutes to hours after taking relatively high 
doses of certain drugs such as cannabis, cocaine, and 
hallucinogens. It may take longer periods of sustained 
intoxication to produce delirium symptoms with alco- 
hol, anxiolytics, or narcotics (APA, 2000). 

Substance-Withdrawal Delirium 

Withdrawal delirium symptoms develop after reduction 
or termination of sustained, usually high-dose use of 
certain substances, such as alcohol, sedatives, hypnotics, 
or anxiolytics (APA, 2000). The duration of the delirium 
is directly related to the half-life of the substance in- 
volved and may last from a few hours to 2 to 4 weeks. 

Delirium Due to Multiple Etiologies 

This diagnosis is used when the symptoms of delirium 
are brought on by more than one cause. For example, 
the delirium may be related to more than one general 
medical condition or it may be a result of the com- 
bined effects of a general medical condition and sub- 
stance use (APA, 2000). 


Clinical Findings, Epidemiology, 
and Course 

This disorder constitutes a large and growing public 
health problem. Scientists estimate that 5.3 million 
people in the United States currently have Alzheimer's 
disease (AD), the most common form of dementia, and 
the prevalence (the number of people with the disease 

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A loss of previous levels of cognitive, executive, 
and memory function in a state of full alertness 
(Bourgeois etal, 2008). 

at any one time) doubles for every 5 -year age group 
beyond age 65 (National Institute on Aging [NIA], 
2008). The NIAs Aging, Demographics, and Memory 
Study revealed that the disease affects 5 percent of 
people from ages 71 to 79, 24 percent of people ages 
80 to 89, and 37 percent of those ages 90 and older 
(Plassman et al, 2007). Researchers estimate that by 
2050, the number of individuals aged 65 and older with 
AD will be between 1 1 and 16 million if current popu- 
lation trends continue and no preventive treatments 
become available (Alzheimer's Association, 2010). After 
heart disease and cancer, AD is the third most costly 
disease to society, accounting for $100 billion in yearly 
costs (NIA, 2008). This proliferation is not the result 
of an "epidemic." It has occurred because more peo- 
ple now survive into the high-risk period for dementia, 
which is middle age and beyond. 

Dementia can be classified as either primary or sec- 
ondary. Primary dementias are those, such as AD, in 
which the dementia itself is the major sign of some 
organic brain disease not directly related to any other 
organic illness. Secondary dementias are caused by 
or related to another disease or condition, such as HIV 
disease or a cerebral trauma. 

In dementia, impairment is evident in abstract think- 
ing, judgment, and impulse control. The conventional 
rules of social conduct are often disregarded. Behavior 
may be uninhibited and inappropriate. Personal ap- 
pearance and hygiene are often neglected. 

Language may or may not be affected. Some indi- 
viduals may have difficulty naming objects, or the lan- 
guage may seem vague and imprecise. In severe forms 
of dementia, the individual may not speak at all (apha- 
sia). The client may know his or her needs, but may not 
know how to communicate those needs to a caregiver. 

Personality change is common in dementia and 
may be manifested by either an alteration or accen- 
tuation of premorbid characteristics. For example, an 
individual who was previously very socially active may 
become apathetic and socially isolated. A previously 
neat person may become markedly untidy in his or her 
appearance. Conversely, an individual who may have 
had difficulty trusting others prior to the illness may 

exhibit extreme fear and paranoia as manifestations of 
the dementia. 

The reversibility of a dementia is a function of 
the underlying pathology and of the availability and 
timely application of effective treatment (APA, 2000). 
Truly reversible dementia occurs in only a small per- 
centage of cases and might be more appropriately 
termed temporary dementia. Reversible dementia can 
occur as a result of cerebral lesions, depression, side 
effects of certain medications, normal pressure hydro- 
cephalus, vitamin or nutritional deficiencies (especially 
B 12 or folate), central nervous system infections, and 
metabolic disorders (Srikanth & Nagaraja, 2005). In 
most clients, dementia runs a progressive, irreversible 

As the disease progresses, apraxia, which is the in- 
ability to carry out motor activities despite intact motor 
function, may develop. The individual may be irritable, 
moody, or exhibit sudden outbursts over trivial issues. 
The ability to work or care for personal needs inde- 
pendently will no longer be possible. These individuals 
can no longer be left alone because they do not com- 
prehend their limitations and are therefore at serious 
risk for accidents. Wandering away from the home or 
care setting often becomes a problem. 

Several causes have been described for the syndrome 
of dementia (see section on etiological implications), 
but dementia of the Alzheimer's type (DAT) accounts 
for 50 to 60 percent of all cases (Sadock & Sadock, 
2007). The progressive nature of symptoms associ- 
ated with DAT has been described according to stages 
(Alzheimer's Association, 2009; NIA, 2009; Stanley, 
Blair, & Beare, 2005): 

Stage 1. No apparent symptoms: In the first stage of 
the illness, there is no apparent decline in memory. 

Stage 2. Forgetfulness: The individual begins to lose 
things or forget names of people. Losses in short- 
term memory are common. The individual is aware 
of the intellectual decline and may feel ashamed, 
becoming anxious and depressed, which in turn 
may worsen the symptoms. Maintaining organiza- 
tion with lists and a structured routine provide some 
compensation. These symptoms often are not ob- 
served by others. 

Stage 3. Mild cognitive decline: In this stage, there 
is interference with work performance, which be- 
comes noticeable to coworkers. The individual may 
get lost when driving his or her car. Concentration 
may be interrupted. There is difficulty recalling 
names or words, which becomes noticeable to fam- 
ily and close associates. A decline occurs in the abil- 
ity to plan or organize. 

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Stage 4. Mild-to-moderate cognitive decline; con- 
fusion: At this stage, the individual may forget ma- 
jor events in personal history, such as his or her own 
child's birthday; experience declining ability to per- 
form tasks, such as shopping and managing personal 
finances; or be unable to understand current news 
events. He or she may deny that a problem exists 
by covering up memory loss with confabulation 
(creating imaginary events to fill in memory gaps). 
Depression and social withdrawal are common. 

Stage 5. Moderate cognitive decline; early demen- 
tia: In the early stages of dementia, the individual 
loses the ability to perform some activities of daily 
living (ADLs) independently, such as hygiene, dress- 
ing, and grooming, and requires some assistance to 
manage these on an ongoing basis. They may for- 
get addresses, phone numbers, and names of close 
relatives. They may become disoriented about place 
and time, but they maintain knowledge about them- 
selves. Frustration, withdrawal, and self-absorption 
are common. 

Stage 6. Moderate-to-severe cognitive decline; 
middle dementia: At this stage, the individual may 
be unable to recall recent major life events or even 
the name of his or her spouse. Disorientation to sur- 
roundings is common, and the person may be un- 
able to recall the day, season, or year. The person is 
unable to manage ADLs without assistance. Urinary 
and fecal incontinence are common. Sleeping be- 
comes a problem. Psychomotor symptoms include 
wandering, obsessiveness, agitation, and aggression. 
Symptoms seem to worsen in the late afternoon 
and evening — a phenomenon termed sundown- 
ing. Communication becomes more difficult, with 
increasing loss of language skills. Institutional care 
is usually required at this stage. 

Stage 7. Severe cognitive decline; late dementia: 
In the end stages of DAT, the individual is unable 
to recognize family members. He or she most com- 
monly is bedfast and aphasic. Problems of immobil- 
ity, such as decubiti and contractures, may occur. 

Stanley and associates (2005) describe the late stages 
of dementia in the following manner: 

During late-stage dementia, the person becomes 
more chairbound or bedbound. Muscles are rigid, 
contractures may develop, and primitive reflexes may 
be present. The person may have very active hands 
and repetitive movements, grunting, or other vocali- 
zations. There is depressed immune system func- 
tion, and this impairment coupled with immobility 
may lead to the development of pneumonia, urinary 
tract infections, sepsis, and pressure ulcers. Appetite 

decreases and dysphagia is present; aspiration is com- 
mon. Weight loss generally occurs. Speech and lan- 
guage are severely impaired, with greatly decreased 
verbal communication. The person may no longer 
recognize any family members. Bowel and blad- 
der incontinence are present and caregivers need to 
complete most ADLs for the person. The sleep-wake 
cycle is greatly altered, and the person spends a lot 
of time dozing and appears socially withdrawn and 
more unaware of the environment or surroundings. 
Death may be caused by infection, sepsis, or aspira- 
tion, although there are not many studies examining 
cause of death, (p. 358) 

Etiological Implications 

The disorders of dementia are differentiated by their 
etiology, although they share a common symptom pres- 
entation. Categories of dementia include the following: 

• Dementia of the Alzheimer's type 

• Vascular dementia 

• Dementia due to HIV disease 

• Dementia due to head trauma 

• Dementia due to Lewy body disease 

• Dementia due to Parkinson's disease 

• Dementia due to Huntington's disease 

• Dementia due to Pick's disease 

• Dementia due to Creutzfeldt-Jakob disease 

• Dementia due to other general medical conditions 

• Substance-induced persisting dementia 

• Dementia due to multiple etiologies 

Dementia of the Alzheimer's Type 

This disorder is characterized by the syndrome of 
symptoms identified as dementia in the DSM-IV-TR 
and in the seven stages described previously. The on- 
set of symptoms is slow and insidious, and the course 
of the disorder is generally progressive and deteriorat- 
ing. The DSM-IV-TR further categorizes this disorder 
as early onset (first symptoms occurring at age 65 or 
younger) or late onset (first symptoms occurring after 
age 65) and by the clinical presentation of behavioral 
disturbance (such as wandering or agitation) superim- 
posed on the dementia. 

Refinement of diagnostic criteria now enables cli- 
nicians to use specific clinical features to identify the 
disease with considerable accuracy. Examination by 
computerized tomography (CT) scan or magnetic res- 
onance imaging (MRI) reveals a degenerative pathol- 
ogy of the brain that includes atrophy, widened corti- 
cal sulci, and enlarged cerebral ventricles (Figs. 12-1 
and 12-2). Microscopic examinations reveal numerous 

2338_Ch12_231-265.indd 237 

8/31/10 6:00:22 PM 


U tin 

„ O 

Sh 5h 

c 8 


H - A 

P4 , 

B -5 

^ £> 

N O 

i3 ■ 

o bo 

p .3 

5 bp 

CO <j 

Exlimie Shnnhape or 

FIGURE 12-1 Changes in the Alzheim- 
er's brain. (A) Metabolic activity in a normal 
brain. (B) Diminished metabolic activity in 
the Alzheimer's diseased brain. (C) Late-stage 
Alzheimer's disease with generalized atrophy 
and enlargement of the ventricles and sulci. 

neurofibrillary tangles and senile plaques in the brains 
of clients with Alzheimer's disease. These changes ap- 
parently occur as a part of the normal aging process. 
However, in clients with DAT, they are found in dra- 
matically increased numbers, and their profusion is 
concentrated in the hippocampus and certain parts of 
the cerebral cortex. 


The exact cause of Alzheimer's disease is unknown. 
Several hypotheses have been supported by varying 
amounts and quality of data. These hypotheses include 
the following: 

• Acetylcholine alterations: Research has indi- 
cated that in the brains of AD clients, the enzyme 
required to produce acetylcholine is dramatically 
reduced. The reduction seems to be greatest in the 
nucleus basalis of the inferior medial forebrain area 
(Cummings & Mega, 2003). This decrease in pro- 
duction of acetylcholine reduces the amount of the 
neurotransmitter that is released to cells in the cor- 
tex and hippocampus, resulting in a disruption of 
the cognitive processes. Other neurotransmitters 
implicated in the pathology and clinical symp- 
toms of AD include norepinephrine, serotonin, 

dopamine, and the amino acid glutamate. It has been 
proposed that in dementia, excess glutamate leads 
to overstimulation of the N-methyl-D- aspartate 
(NMDA) receptors, leading to increased intracellu- 
lar calcium and subsequent neuronal degeneration 
and cell death. 

Plaques and tangles: As mentioned previously, 
an overabundance of structures called plaques and 
tangles appear in the brains of individuals with AD. 
The plaques are made of a protein called amyloid 
beta (A(3), a fragment of a larger protein called amy- 
loid precursor protein (APP) (NLA, 2008). Plaques 
are formed when these fragments clump together 
and mix with molecules and other cellular matter. 
Tangles are formed from a special kind of cellu- 
lar protein called tau protein, whose function it is 
to provide stability to the neuron. In AD, the tau 
protein is chemically altered (NIA, 2008). Strands 
of the protein become tangled together, interfering 
with the neuronal transport system. It is not known 
whether the plaques and tangles cause AD or are 
a consequence of the AD process. It is thought 
that the plaques and tangles contribute to the de- 
struction and death of neurons, leading to memory 
failure, personality changes, inability to carry out 
ADLs, and other features of the disease. 

2338_Ch12_231-265.indd 238 

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Brain Cross Sections 



Sulcus & § 

o P 

Gyrus pr g* 

5" p" 

3 ! 


3 P 



FIGURE 12—2 Neurobiology of Alzheimer's disease. 


A decrease in the neurotransmitter acetylcholine has been implicated 
in the etiology of Alzheimer's disease. Cholinergic sources arise from 
the brainstem and the basal forebrain to supply areas of the basal 
ganglia, thalamus, limbic structures, hippocampus, and cerebral cortex. 

Cell bodies of origin for the serotonin pathways lie within the 
raphe nuclei located in the brainstem. Those for norepinephrine 
originate in the locus ceruleus. Projections for both neurotransmitters 
extend throughout the forebrain, prefrontal cortex, cerebellum, and 
limbic system. Dopamine pathways arise from areas in the midbrain 
and project to the frontal cortex, limbic system, basal ganglia, and 
thalamus. Dopamine neurons in the hypothalamus innervate the 
posterior pituitary. 

Glutamate, an excitatory neurotransmitter, has largely descending 
pathways, with highest concentrations in the cerebral cortex. It is 
also found in the hippocampus, thalamus, hypothalamus, cerebellum, 
and spinal cord. 


Areas of the brain affected by Alzheimer's disease and associated 
symptoms include the following: 

• Frontal lobe: Impaired reasoning ability; unable to solve problems 
and perform familiar tasks; poor judgment; inability to evaluate 
the appropriateness of behavior; aggressiveness. 

• Parietal lobe: Impaired orientation ability; impaired visuospatial 
skills (unable to remain oriented within own environment). 

• Occipital lobe: Impaired language interpretation; unable to recog- 
nize familiar objects 

• Temporal lobe: Inability to recall words; inability to use words 
correctly (language comprehension); in late stages, some clients 
experience delusions and hallucinations. 

• Hippocampus: Impaired memory; short-term memory is 
affected initially; later, the individual is unable to form 
new memories. 

• Amygdala: Impaired emotions: depression, anxiety, fear, personal- 
ity changes, apathy, paranoia. 

• Neurotransmitters: Alterations in acetylcholine, dopamine, 
norepinephrine, serotonin, and others may play a role in 
behaviors such as restlessness, sleep impairment, mood, 
and agitation. 


1 . Cholinesterase inhibitors (e.g., tacrine, donepezil, rivastigmine, 
and galantamine) act by inhibiting acetylcholinesterase, which 
slows the degradation of acetylcholine, thereby increasing con- 
centrations of the neurotransmitter in the brain. Most common 
side effects include dizziness, gastrointestinal upset, fatigue, and 

2. NMDA receptor antagonists (e.g., memantine) act by blocking 
NMDA receptors from excessive glutamate, preventing continu- 
ous influx of calcium into the cells, and ultimately slowing down 
neuronal degradation. Possible side effects include dizziness, 
headache, and constipation. 

2338_Ch12_231-265.indd 239 

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• Head trauma: The etiology of AD has been associ- 
ated with serious head trauma (Tesco et al, 2007). 
Studies have shown that some individuals who had 
experienced head trauma had subsequently (after 
years) developed AD. This hypothesis is being in- 
vestigated as a possible cause. Munoz and Feldman 
(2000) report an increased risk for AD in individu- 
als who are both genetically predisposed and who 
experience traumatic head injury. 

• Genetic factors: There is clearly a familial pattern 
with some forms of Alzheimer's disease. Some fami- 
lies exhibit a pattern of inheritance that suggests 
possible autosomal- dominant gene transmission 
(Sadock & Sadock, 2007). Some studies indicate 
that early-onset cases are more likely to be famil- 
ial than late-onset cases and that from one third 
to one half of all cases may be of the genetic form. 
Some research indicates that there is a link between 
early-onset Alzheimer's disease and gene mutations 
found on chromosomes 21, 14, and 1 (Alzheimer's 
Disease Education & Referral [ADEAR], 2008). 
Mutations on chromosome 21 cause the forma- 
tion of abnormal APR Mutations on chromosome 
14 cause abnormal presenilin 1 (PS-1) to be made, 
and mutations on chromosome 1 leads to the for- 
mation of abnormal presenilin 2 (PS-2). Each of 
these mutations results in an increased amount of 
the A(3 protein that is a major component of the 
plaques associated with AD. Individuals with Down 
syndrome (who carry an extra copy of chromosome 
21) have been found to be unusually susceptible to 
AD (Blazer, 2008). 

Two genetic variants have been identified as risk 
factors for late-onset AD. The apolipoprotein E epsi- 
lon 4 (ApoE e4) gene, found on chromosome 19, was 
identified in 1993. Its exact role in the development 
of AD is not yet clear (ADEAR, 2008). A second ge- 
netic variant, the SORL1 gene, was identified in 2007 
(Rogaeva et al, 2007). The researchers believe that 
the altered gene function results in increasing pro- 
duction of the toxic A(3 protein and subsequently the 
plaques associated with AD. 

Vascular Dementia 

In this disorder, the clinical syndrome of dementia is 
due to significant cerebrovascular disease. The blood 
vessels of the brain are affected, and progressive intel- 
lectual deterioration occurs. Vascular dementia is the 
second most common form of dementia, ranking after 
Alzheimer's disease (Bourgeois et al, 2008). 

Vascular dementia differs from Alzheimer's disease 
in that it has a more abrupt onset and runs a highly 

variable course. Progression of the symptoms occurs in 
"steps" rather than as a gradual deterioration; that is, at 
times the dementia seems to clear up and the individual 
exhibits fairly lucid thinking. Memory may seem bet- 
ter, and the client may become optimistic that improve- 
ment is occurring, only to experience further decline of 
functioning in a fluctuating pattern of progression. This 
irregular pattern of decline appears to be an intense 
source of anxiety for the client with this disorder. 

In vascular dementia, clients suffer the equivalent 
of small strokes that destroy many areas of the brain. 
The pattern of deficits is variable, depending on which 
regions of the brain have been affected (APA, 2000). 
Certain focal neurological signs are commonly seen 
with vascular dementia, including weaknesses of the 
limbs, small-stepped gait, and difficulty with speech. 

The disorder is more common in men than in women 
(APA, 2000). Arvanitakis (2000) states: 

Prognosis for patients with vascular dementia 
is worse than that for Alzheimer's patients. The 
three-year mortality rate in cases over the age of 
85 years old is quoted at 67 percent as compared to 
42 percent in Alzheimer's disease, and 23 percent 
in non-demented individuals. However, outcome is 
ultimately dependent on the underlying risk factors 
and mechanism of disease, and further studies taking 
these distinctions into account are warranted. 

The diagnosis can be subtyped when the dementia 
is superimposed with symptoms of delirium, delusions, 
or depressed mood. 


The cause of vascular dementia is directly related to an 
interruption of blood flow to the brain. Symptoms re- 
sult from death of nerve cells in regions nourished by 
diseased vessels. Various diseases and conditions that 
interfere with blood circulation have been implicated. 

High blood pressure is thought to be one of the 
most significant factors in the etiology of multiple small 
strokes or cerebral infarcts. Hypertension leads to dam- 
age to the lining of blood vessels. This can result in rup- 
ture of the blood vessel, with subsequent hemorrhage, or 
an accumulation of fibrin in the vessel, with intravascu- 
lar clotting and inhibited blood flow (DeMartinis, 2005). 
Dementia also can result from infarcts related to occlu- 
sion of blood vessels by particulate matter that travels 
through the bloodstream to the brain. These emboli may 
be solid (e.g., clots, cellular debris, platelet aggregates), 
gaseous (e.g., air, nitrogen), or liquid (e.g., fat, following 
soft tissue trauma or fracture of long bones). 

Cognitive impairment can occur with multiple small 
infarcts (sometimes called "silent strokes") over time 

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or with a single cerebrovascular insult that occurs in 
a strategic area of the brain. An individual may have 
both vascular dementia and AD simultaneously. This is 
referred to as mixed dementia, the prevalence of which is 
likely to increase as the population ages (Langa, Foster, 
& Larson, 2004). 

Dementia Due to HIV 

Infection with the HIV- 1 produces a dementing illness 
called HIV- 1 -associated cognitive/motor complex. A less se- 
vere form, known as HIV-1 -associated minor cognitive/ 
motor disorder, also occurs. The severity of symptoms is 
correlated to the extent of brain pathology. The immune 
dysfunction associated with HIV disease can lead to 
brain infections by other organisms, and the HIV- 1 also 
appears to cause dementia directly. In the early stages, 
neuropsychiatric symptoms may be manifested by barely 
perceptible changes in a person's normal psychological 
presentation. Severe cognitive changes, particularly con- 
fusion, changes in behavior, and sometimes psychoses, 
are not uncommon in the later stages. 

With the advent of the highly active antiretroviral 
therapies (HAART), incidence rates of dementia as- 
sociated with HIV disease have been on the decline. 
However, it is possible that the prolonged life span of 
HIV-infected patients taking medications may actually 
increase the numbers of individuals living with HIV- 
associated dementia. 

Dementia Due to Head Trauma 

Serious head trauma can result in symptoms associ- 
ated with the syndrome of dementia. Amnesia is the 
most common neurobehavioral symptom following 
head trauma, and a degree of permanent disturbance 
may persist (Bourgeois et al, 2008). Repeated head 
trauma, such as the type experienced by boxers, can 
result in dementia pugilistica, a syndrome characterized 
by emotional lability, dysarthria, ataxia, and impulsiv- 
ity (Sadock & Sadock, 2007). 

Dementia Due to Lewy Body Disease 

Clinically, Lewy body disease is fairly similar to AD; 
however, it tends to progress more rapidly, and there 
is an earlier appearance of visual hallucinations and 
parkinsonian features (Rabins, 2006). This disor- 
der is distinctive by the presence of Lewy bodies — 
eosinophilic inclusion bodies — seen in the cerebral 
cortex and brainstem (Andreasen & Black, 2006). 
These patients are highly sensitive to extrapyramidal 

effects of antipsychotic medications. The disease is 
progressive and irreversible and may account for as 
many as 25 percent of all dementia cases. 

Dementia Due to Parkinson's Disease 

Dementia is observed in as many as 60 percent of cli- 
ents with Parkinson's disease (Bourgeois et al, 2008). In 
this disease, there is a loss of nerve cells located in the 
substantia nigra, and dopamine activity is diminished, 
resulting in involuntary muscle movements, slow- 
ness, and rigidity. Tremor in the upper extremities is 
characteristic. In some instances, the cerebral changes 
that occur in dementia of Parkinson's disease closely 
resemble those of AD. 

Dementia Due to Huntington's Disease 

Huntington's disease is transmitted as a Mendelian 
dominant gene. Damage is seen in the areas of the 
basal ganglia and the cerebral cortex. The onset of 
symptoms (i.e., involuntary twitching of the limbs or 
facial muscles, mild cognitive changes, depression and 
apathy) usually occurs between age 30 and 50 years. 
The client usually declines into a profound state of 
dementia and ataxia. The average duration of the dis- 
ease is based on age at onset. One study concluded that 
juvenile-onset and late-onset clients have the shortest 
duration (Foroud et al, 1999). In this study, the median 
duration of the disease was 2 1 .4 years. 

Dementia Due to Pick's Disease 

The cause of Pick's disease is unknown, but a genetic 
factor appears to be involved. The clinical picture is 
strikingly similar to that of AD. One major difference 
is that the initial symptom in Pick's disease is usually 
personality change, whereas the initial symptom in AD 
is memory impairment. Studies reveal that pathology 
of Pick's disease results from atrophy in the frontal and 
temporal lobes of the brain, in contrast to AD, which is 
more widely distributed. 

Dementia Due to Creutzfeldt-Jakob 

Creutzfeldt-Jakob disease is an uncommon neuro- 
degenerative disease caused by a transmissible agent 
known as a "slow virus" or prion (APA, 2000). Five to 
15 percent of cases have a genetic component. The 
clinical presentation is typical of the syndrome of 

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dementia, along with involuntary movements, mus- 
cle rigidity, and ataxia. Symptoms may develop at any 
age in adults, but typically occur between ages 40 and 
60 years. The clinical course is extremely rapid, with 
the progression from diagnosis to death in less than 
2 years (Rentz, 2008). 

Dementia Due to Other General Medical 

A number of other general medical conditions can cause 
dementia. Some of these include endocrine conditions 
(e.g., hypoglycemia, hypothyroidism), pulmonary dis- 
ease, hepatic or renal failure, cardiopulmonary insuf- 
ficiency, fluid and electrolyte imbalances, nutritional 
deficiencies, frontal or temporal lobe lesions, central 
nervous system (CNS) or systemic infections, uncon- 
trolled epilepsy, and other neurological conditions such 
as multiple sclerosis (APA, 2000). 

Substance-Induced Persisting Dementia 

The features associated with this type of dementia are 
those associated with dementias in general; however, 
evidence must exist from the history, physical exami- 
nation, or laboratory findings to show that the defi- 
cits are etiologically related to the persisting effects of 
substance use (APA, 2000). The term persisting is used 
to indicate that the dementia persists long after the ef- 
fects of substance intoxication or substance withdrawal 
have subsided. The DSM-IV-TR identifies the follow- 
ing types of substances with which persisting dementia 
is associated: 

1. Alcohol 

2. Inhalants 

3. Sedatives, hypnotics, and anxiolytics 

4. Medications 

a. Anticonvulsants 

b. Intrathecal methotrexate 

5. Toxins 

a. Lead 

b. Mercury 

c. Carbon monoxide 

d. Organophosphate insecticides 

e. Industrial solvents 

The diagnosis is made according to the specific 
etiological substance involved. For example, if the 
substance known to cause the dementia is alcohol, the 
diagnosis is Alcohol-Induced Persisting Dementia. 
If the exact substance presumed to be causing the 

dementia is unknown, the diagnosis would be Un- 
known Substance-Induced Persisting Dementia. 

Dementia Due to Multiple Etiologies 

This diagnosis is used when the symptoms of dementia 
are attributed to more than one cause. For example, 
the dementia may be related to more than one medical 
condition or to the combined effects of a general med- 
ical condition and the long-term use of a substance 
(APA, 2000). 

The etiological factors associated with delirium and 
dementia are summarized in Box 12-1. 


Amnestic disorders are characterized by an inability to 
learn new information (short-term memory deficit) de- 
spite normal attention and an inability to recall previ- 
ously learned information (long-term memory deficit). 
Events from the remote past often are recalled more 
easily than recently occurring ones. The syndrome dif- 
fers from dementia in that there is no impairment in 
abstract thinking or judgment, no other disturbances of 
higher cortical function, and no personality change. 

Profound amnesia may result in disorientation to 
place and time, but rarely to self (APA, 2000). The in- 
dividual may engage in confabulation — the creation of 
imaginary events to fill in memory gaps. 

Some individuals will continue to deny that they have 
a problem despite evidence to the contrary. Others may 
acknowledge that a problem exists, but appear uncon- 
cerned. Apathy, lack of initiative, and emotional bland- 
ness are common. The person may appear friendly and 
agreeable, but the emotionality is superficial. 

The onset of symptoms may be acute or insidious, 
depending on the pathological process causing the 
amnestic disorder. Duration and course of the illness 
may be quite variable and are also correlated with ex- 
tent and severity of the cause. 



The inability to retain or recall past experiences. 
The condition may be temporary or permanent, de- 
pending on etiology. 

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Box 12-1 Etiological Factors Implicated in the Development of Delirium and/or Dementia 

Biological Factors 

Hypoxia: any condition leading to a deficiency of oxygen 
to the brain 

Nutritional deficiencies: vitamins (particularly B and C); 
protein; fluid and electrolyte imbalances 

Metabolic disturbances: porphyria; encephalopathies re- 
lated to hepatic, renal, pancreatic, or pulmonary insuffi- 
ciencies; hypoglycemia 

Endocrine dysfunction: thyroid, parathyroid, adrenal, pan- 
creas, pituitary 

Cardiovascular disease: stroke, cardiac insufficiency, athero- 

Primary brain disorders: epilepsy, Alzheimer's disease, 
Pick's disease, Huntington's disease, multiple sclerosis, 
Parkinson's disease 

Infections: encephalitis, meningitis, pneumonia, septicemia, 
neurosyphilis (dementia paralytica), HIV disease, acute 
rheumatic fever, Creutzfeldt-Jakob disease 

Intracranial neoplasms 

Congenital defects: prenatal infections, such as first- 
trimester maternal rubella 

Exogenous Factors 

Birth trauma: prolonged labor, damage from use of forceps, 
other obstetric complications 

Cranial trauma: concussion, contusions, hemorrhage, he- 

Volatile inhalant compounds: gasoline, glue, paint, paint 
thinners, spray paints, cleaning fluids, typewriter cor- 
rection fluid, varnishes, and lacquers 

Heavy metals: lead, mercury, manganese 

Other metallic elements: aluminum 

Organic phosphates: various insecticides 

Substance abuse/dependence: alcohol, amphetamines, caf- 
feine, cannabis, cocaine, hallucinogens, inhalants, nicotine, 
opioids, phencyclidine, sedatives, hypnotics, anxiolytics 

Other medications: anticholinergics, antihistamines, anti- 
depressants, antipsychotics, antiparkinsonians, antihyper- 
tensives, steroids, digitalis 

Etiological Implications 

Amnestic disorders share a common symptom presen- 
tation of memory impairment, but are differentiated in 
the DSM-IV-TR (APA, 2000) according to the follow- 
ing etiology: 

• Amnestic disorder due to a general medical condition 

• Substance-induced persisting amnestic disorder 

Amnestic Disorder Due to a General 
Medical Condition 

In this type of amnestic disorder, evidence must exist 
from the history, physical examination, or laboratory 
findings to show that the memory impairment is the 
direct physiological consequence of a general medical 
condition (APA, 2000). The diagnosis is specified fur- 
ther by indicating whether the symptoms are transient 
(present for no more than 1 month) or chronic (present 
for more than 1 month). 

General medical conditions that may be associated 
with amnestic disorder include head trauma, cerebro- 
vascular disease, cerebral neoplastic disease, cerebral 
anoxia, herpes simplex encephalitis, poorly controlled 
insulin- dependent diabetes, and surgical intervention 
to the brain (Andreasen & Black, 2006; APA, 2000). 

Transient amnestic syndromes can occur from cere- 
brovascular disease, cardiac arrhythmias, migraine, thy- 
roid disorders, and epilepsy (Bourgeois et al, 2008). 

Substance-Induced Persisting Amnestic 

In this disorder, evidence must exist from the history, 
physical examination, or laboratory findings that the 
memory impairment is related to the persisting effects 
of substance use (e.g., a drug of abuse, a medication, 
or toxin exposure) (APA, 2000). The term persisting 
is used to indicate that the symptoms exist long after 
the effects of substance intoxication or withdrawal 
have subsided. The DSM-IV-TR identifies the fol- 
lowing substances with which amnestic disorder can 
be associated: 

1. Alcohol 

2. Sedatives, hypnotics, and anxiolytics 

3. Medications 

a. Anticonvulsants 

b. Intrathecal methotrexate 

4. Toxins 

a. Lead 

b. Mercury 

c. Carbon monoxide 

d. Organophosphate insecticides 

e. Industrial solvents 

The diagnosis is made according to the specific eti- 
ological substance involved. For example, if the sub- 
stance known to be the cause of the amnestic disorder 
is alcohol, the diagnosis would be Alcohol-Induced 
Persisting Amnestic Disorder. 

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Nursing assessment of the client with delirium, demen- 
tia, or persisting amnesia is based on knowledge of the 
symptomatology associated with the various disorders 
described in the beginning of this chapter. Subjective 
and objective data are gathered by various members of 
the health-care team. Clinicians report use of a variety 
of methods for obtaining assessment information. 

Client History 

Nurses play a significant role in acquiring the client 
history, including the specific mental and physical 
changes that have occurred and the age at which the 
changes began. If the client is unable to relate infor- 
mation adequately, the data should be obtained from 
family members or others who would be aware of the 
client's physical and psychosocial history. 

From the client history, nurses should assess the fol- 
lowing areas of concern: (1) type, frequency, and sever- 
ity of mood swings, personality and behavioral chang- 
es, and catastrophic emotional reactions; (2) cognitive 
changes, such as problems with attention span, think- 
ing process, problem-solving, and memory (recent and 
remote); (3) language difficulties; (4) orientation to 
person, place, time, and situation; and (5) appropriate- 
ness of social behavior. 

The nurse also should obtain information regard- 
ing current and past medication usage, history of other 
drug and alcohol use, and possible exposure to toxins. 
Knowledge regarding the history of related symptoms 
or specific illnesses (e.g., Huntington's disease, AD, 
Pick's disease, or Parkinson's disease) in other family 
members might be useful. 

Physical Assessment 

Assessment of physical systems by both the nurse and 
the physician has two main emphases: (1) signs of dam- 
age to the nervous system and (2) evidence of diseases 
of other organs that could affect mental function. Dis- 
eases of various organ systems can induce confusion, 
loss of memory, and behavioral changes. These causes 
must be considered in diagnosing cognitive disorders. 
In the neurological examination, the client is asked 
to perform maneuvers or answer questions that are 
designed to elicit information about the condition of 

specific parts of the brain or peripheral nerves. Testing 
will assess mental status and alertness, muscle strength, 
reflexes, sensory perception, language skills, and coor- 
dination. An example of a mental status examination 
for a client with dementia is presented in Box 12-2. 

A battery of psychological tests may be ordered as 
part of the diagnostic examination. The results of these 
tests may be used to make a differential diagnosis be- 
tween dementia and pseudodementia (depression). 
Depression is the most common mental illness in the 
elderly, but it is often misdiagnosed and treated inade- 
quately. Cognitive symptoms of depression may mimic 
dementia, and because of the prevalence of dementia 
in the elderly, diagnosticians are often too eager to 
make this diagnosis. A comparison of symptoms of de- 
mentia and pseudodementia (depression) is presented 
in Table 12-1. Nurses can assist in this assessment by 
carefully observing and documenting these sometimes 
subtle differences. 

Diagnostic Laboratory Evaluations 

The nurse also may be required to help the client fulfill 
the physician's orders for special diagnostic laboratory 
evaluations. Many of these tests are routinely included 
with the physical examination and may include evalua- 
tion of blood and urine samples to test for various infec- 
tions; hepatic and renal dysfunction; diabetes or hypogly- 
cemia; electrolyte imbalances; metabolic and endocrine 
disorders; nutritional deficiencies; and presence of toxic 
substances, including alcohol and other drugs. 

Other diagnostic evaluations may be made by electro- 
encephalogram (EEG), which measures and records the 
brain's electrical activity. With CT scan, an image of the 
size and shape of the brain can be obtained. MRI is used 
to obtain a computerized image of soft tissue in the body. 
It provides a sharp, detailed picture of the tissues of the 
brain. A lumbar puncture may be performed to examine 
the cerebrospinal fluid for evidence of CNS infection 
or hemorrhage. Positron emission tomography (PET) 
is used to reveal the metabolic activity of the brain, an 
evaluation some researchers believe is important in 
the diagnosis of AD. Researchers at the University of 
California Los Angeles used PET following injections of 
FDDNP (a molecule that binds to plaques and tangles in 
vitro) (Small et al, 2006). With this test, the researchers 
were able to distinguish between subjects with AD, mild 
cognitive impairment, and those with no cognitive im- 
pairment. With FDDNP-PET, researchers are able to 
accurately diagnose AD in its earlier stages and track dis- 
ease progression noninvasively in a clinical setting. The 

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Box 12-2 Mental Status Examination for Dementia 

Patient Name 







Ask client to name as many animals as he/she can. (Time: 60 seconds) 10 points 

(Score 1 point/2 animals) 


a. Point to the ceiling. 1 point 

b. Point to your nose and the window. 1 point 

c. Point to your foot, the door, and ceiling. 1 point 

d. Point to the window, your leg, the door, and your thumb. 1 point 


Ask the client to name the following as you point to them: 

a. Watch stem (winder) 1 point 

b. Teeth 1 point 

c. Sole of shoe 1 point 

d. Buckle of belt 1 point 

e. Knuckles 1 point 


a. Date 2 points 

b. Day of week 2 points 

c. Month 1 point 

d. Year 1 point 


Tell the client: "I'm going to tell you three words, which I want you to remember." 
Have the client repeat the three words after they are initially presented, and then 
say that you will ask him/her to remember the words later. Continue with the 
examination, and at intervals of 5 and 10 minutes, ask the client to recall the 
words. Four different sets of words are provided here. 

a. Brown (fan) (grape) 2 points each: 

b. Honesty (loyalty) (happiness) 2 points each: 

c. Tulip (carrot) (stocking) 2 points each: 

d. Eyedropper (ankle) (toothbrush) 2 points each: 


Tell the client: "I'm going to read you a short story, which I want you to 13 points 

remember. Listen closely to what I read because I will ask you to tell me 

the story when I finish." Read the story slowly and carefully, but without 

pausing at the slash marks. After completing the paragraph, tell the client 

to retell the story as accurately as possible. Record the number of correct 

memories (information within the slashes) and describe confabulation if it 

is present. (1 point = 1 remembered item [13 maximum points]) 

It was July / and the Rogers / had packed up / their four children / 

in the station wagon / and were off/ on vacation. 

They were taking / their yearly trip / to the beach / at Gulf Shores. 

This year / they were making / a special / 1-day stop / at The Aquarium / in New Orleans. 

After a long day's drive / they arrived / at the motel / only to discover / that in their excitement / 

they had left / the twins / and their suitcases / in the front yard. 

Client's Score 

5 min 10 min 


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Box 12-2 Mental Status Examination for Dementia— cont'd 


Tell the client that you are going to hide some objects around the 
office (desk, bed) and that you want him/her to remember where 
they are. Hide four or five common objects (e.g., keys, pen, reflex hammer) 
in various places in the client's sight. After a delay of several minutes, 
ask the client to find the objects. (1 point per item found) 

a. Coin 

b. Pen 

c. Comb 

d. Keys 

e. Fork 


Tell the client that you are going to read a list of words two at a time. 
The client will be expected to remember the words that go together 
(e.g., big — little). When he/she is clear on the directions, read the first 
list of words at the rate of one pair per second. After reading the first 
list, test for recall by presenting the first recall list. Give the first word 
of a pair and ask for the word that was paired with it. Correct incorrect responses 
and proceed to the next pair. After the first recall has been completed, allow 
a 10-second delay and continue with the second presentation and recall lists. 
Presentation Lists 

1 point 
1 point 
1 point 
1 point 
1 point 


a. High — Low 

b. House — Income 

c. Good — Bad 

d. Book — Page 

Recall Lists 


Good — Bad 
Book — Page 
High — Low 
House — Income 


a. House 



b. Book 



c. High 



d. Good 




Ask client to reconstruct this drawing and to draw the 
other 2 items: 

2 points 
2 points 
2 points 

2 points 

3 points 

Draw a daisy in a flowerpot. 

3 points 

Draw a clock with all the numbers and set the clock at 2:30. 

3 points 

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Box 12-2 Mental Status Examination for Dementia— cont'd 


a. Addition 108 

+ 79 

1 point 

b. Subtraction 605 


1 point 

c. Multiplication 108 


1 point 

d. Division 

559 + 43 

1 point 


Tell the client to explain the following sayings. Record the answers. 

a. Don't cry over spilled milk. 

2 points 

b. Rome wasn't built in a day. 

2 points 

c. A drowning man will clutch at a straw. 

2 points 

d. A golden hammer can break down an iron door. 

2 points 

e. The hot coal burns, the cold one blackens. 

2 points 


a. Turnip Cauliflower 

b. Car. Airplane 

c. Desk Bookcase 

d. Poem Novel 

e. Horse Apple 

Normal Individuals 

2 points 
2 points 
2 points 
2 points 
2 points 
Maximum: 100 points 
Clients With Alzheimer's Disease 

Age Group 

Mean Score 


80.9 (9.7) 


82.3 (8.6) 


75.5 (10.5) 






Mean Score (standard deviation) 

SI 2 (9.1) 

37.0 (7.8) 


Source: Adapted from Strub, R.L., & Black, F.W. (2000). The mental status examination in neurology (4th ed.). Philadelphia: 
F.A. Davis. With permission. 

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Table 12- 

A Comparison of Dementia and Pseudodementia (Depression) 

Symptom Element 


Pseudodementia (Depression) 

Progression of symptoms 




Progressive deficits; recent memory loss greater 
than remote; may confabulate for memory 
"gaps;" no complaints of loss 

More like forge tfulness; no evidence of progressive 
deficit; recent and remote loss equal; complaints 
of deficits; no confabulation (will more likely 
answer "I don't know") 


Disoriented to time and place; 
may wander in search of the familiar 

Oriented to time and place; no wandering 

Task performance 

Consistently poor performance, but struggles to 

Performance is variable; little effort is put forth 

Symptom severity 

Worse as the day progresses 

Better as the day progresses 

Affective distress 

Appears unconcerned 

Communicates severe distress 




Attention and 




researchers hope that this tool will help clinicians define 
therapeutic interventions before neuronal death occurs, 
thereby retarding the progression of the disease. 

Nursing Diagnosis/Outcome 

Using information collected during the assessment, 
the nurse completes the client database, from which 
the selection of appropriate nursing diagnoses is de- 
termined. Table 12-2 presents a list of client behaviors 
and the NANDA nursing diagnoses that correspond to 
those behaviors and that may be used in planning care 
for the client with a cognitive disorder. 

Outcome Criteria 

The following criteria may be used for measurement 
of outcomes in the care of the client with cognitive 

The Client: 

• Has not experienced physical injury 

• Has not harmed self or others 

• Has maintained reality orientation to the best of his 
or her capability 

• Discusses positive aspects about self and life 

• Fulfills activities of daily living with assistance (or 
for client who is unable: has needs met, as antici- 
pated by caregiver) 

• Is able to communicate with consistent caregiver 


Table 12-3 provides a plan of care for the client with 
a cognitive disorder (irrespective of etiology). Selected 
nursing diagnoses are presented, along with outcome 

criteria, appropriate nursing interventions, and ration- 
ales for each. 

Concept Care Mapping 

The concept map care plan is an innovative approach to 
planning and organizing nursing care (see Chapter 7). 
It is a diagrammatic teaching and learning strategy 
that allows visualization of interrelationships between 
medical diagnoses, nursing diagnoses, assessment data, 
and treatments. An example of a concept map care plan 
for a client with a cognitive disorder is presented in 
Figure 12-3. 

Client/Family Education 

The role of client teacher is important in the psychiat- 
ric area, as it is in all areas of nursing. A list of topics 
for client/family education relevant to cognitive disor- 
ders is presented in Box 12-3. 


In the final step of the nursing process, reassessment 
occurs to determine if the nursing interventions have 
been effective in achieving the intended goals of care. 
Evaluation of the client with cognitive disorders is 
based on a series of short-term goals rather than on 
long-term goals. Resolution of identified problems is 
unrealistic for this client. Instead, outcomes must be 
measured in terms of slowing down the process rather 
than stopping or curing the problem. Evaluation ques- 
tions may include the following: 

1 . Has the client experienced injury? 

2. Does the client maintain orientation to time, 
person, place, and situation most (some) of the 

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Table 12-2 

Assigning Nursing Diagnoses to Behaviors Commonly Associated 
With Cognitive Disorders 


Nursing Diagnoses 

Falls, wandering, poor coordination, confusion, misinterpretation of the environment (illusions, 

hallucinations), lack of understanding of environmental hazards, memory deficits 
Disorientation, confusion, memory deficits, inaccurate interpretation of the environment, 

suspiciousness, paranoia 
Having hallucinations (hears voices, sees visions, feels crawling sensation on skin) 
Aggressiveness, assaultiveness (hitting, scratching, or kicking) 
Inability to name objects/people, loss of memory for words, difficulty finding the right word, 

confabulation, incoherent, screaming and demanding verbalizations 
Inability to perform activities of daily living (ADLs): feeding, dressing, hygiene, toileting 
Expressions of shame and self-degradation, progressive social isolation, apathy, decreased 

activity, withdrawal, depressed mood 

Risk for trauma 

Disturbed thought processes 

Disturbed sensory perception 
Risk for other-directed violence 
Impaired verbal communication 

Self-care deficit (specify) 
Situational low self-esteem 

Ta b I e 1 2-3 Care Plan for the Client With a Cognitive Disorder 


RELATED TO: Impairments in cognitive and psychomotor functioning 

Outcome Criteria 

Nursing Interventions Rationale 

Short-Term Goals 

1. The following measures may be instituted: 1 

. To ensure client safety. 

• Client will call for assistance when 

a. Arrange furniture and other items in the 

ambulating or carrying out other 

room to accommodate client's 

activities (if it is within his or her 


cognitive ability). 

b. Store frequently used items within easy 

• Client will maintain a calm 


demeanor, with minimal agitated 

c. Do not keep bed in an elevated position. 


Pad side rails and headboard if client 

• Client will not experience physical 

has history of seizures. Keep bedrails 


up when client is in bed (if regulations 

Long-Term Goal 


Client will not experience 
physical injury. 

d. Assign room near nurses' station; 
observe frequently. 

e. Assist client with ambulation. 

f. Keep a dim light on at night. 

g. If client is a smoker, cigarettes and 
lighter or matches should be kept at the 
nurses' station and dispensed only when 
someone is available to stay with client 
while he or she is smoking. 

h. Frequently orient client to place, time, 
and situation. 

i. If client is prone to wander, provide an 
area within which wandering can be car- 
ried out safely. 

j. Soft restraints may be required if client 
is very disoriented and hyperactive. 

Continued on following page 

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Table 12-3 Care Plan for the Client With a Cognitive Disorder (Continued) 


RELATED TO: Cerebral degeneration 

EVIDENCED BY: Disorientation, confusion, memory deficits, and inaccurate interpretation of the 


Outcome Criteria 

Short-Term Goals 

• Client will utilize measures pro- 
vided (e.g., clocks, calendars, room 
identification) to maintain reality 

• Client will experience fewer epi- 

sodes of acute confusion. 
Long-Term Goal 

Client will maintain reality orienta- 
tion to the best of his or her cognitive 

Nursing Interventions 

1 . Frequently orient client to reality. 
Use clocks and calendars with large 
numbers that are easy to read. 
Notes and large, bold signs may be 
useful as reminders. Allow client to 
have personal belongings. 

2. Keep explanations simple. Use 
face-to-face interaction. Speak 
slowly and do not shout. 

3 . Discourage rumination of de- 
lusional thinking. Talk about 
real events and real people. But 
remember that the client's level of 
reality is different from the nurse's. 
Do not lie to the client. May need 
to use Validation therapy and 

4. Monitor for medication side 

5. Encourage client to view old 
photograph albums and utilize 
reminiscence therapy. 


1 . All of these items serve to help 
maintain orientation and aid in 
memory and recognition. NOTE: 
There has been some criticism 

in recent years about reality 
orientation (RO) of individuals 
with dementia (particularly those 
with moderate to severe disease 
process), suggesting that constant 
relearning of material contributes 
to problems with mood and self- 
esteem (Spector et al., 2000). (See 
Box 12-4, Validation Therapy.) 

2 . These interventions facilitate com- 
prehension. Shouting may create 
discomfort, and in some instances, 
may provoke anger. 

3 . Rumination promotes disorien- 
tation. Reality orientation and 
validation therapy increase a sense 
of self- worth and personal dignity. 

4. Physiological changes in the 
elderly can alter the body's 
response to certain medications. 
Toxic effects may intensify altered 
thought processes. 

5. These are excellent ways to 
promote self-esteem and provide 
orientation to reality. 


RELATED TO: Disorientation, confusion, and memory deficits 

EVIDENCED BY: Inability to fulfill ADLs 

Outcome Criteria 

Short-Term Goal 

Client will participate in ADLs with 
assistance from caregiver. 


1 . Provide a simple, structured envi- 

a. Identify self-care deficits and 
provide assistance as required. 
Promote independent actions 
as able. 


1 . To minimize confusion. 

2338_Ch12_231-265.indd 250 

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2 . Client safely and security are 
nursing priorities. 


Table 12-3 Care Plan for the Client With a Cognitive Disorder (Continued) 

Long-Term Goals b. Allow plenty of time for client 

• Client will accomplish ADLs to to P erform tasks " 

the best of his or her ability. c. Provide guidance and support 

• Unmlfilled needs will be met by io l ^dependent actions by 

caregivers. talking the client through the 

task one step at a time. 

d. Provide a structured sched- 
ule of activities that does not 
change from day to day. 

e. ADLs should follow usual 
routine as closely as possible. 

f. Provide for consistency in as- 
signment of daily caregivers. 

2. Perform ongoing assessment of 
client's ability to fulfill nutrition- 
al needs, ensure personal safety, 
follow medication regimen, and 
communicate need for assistance 
with activities that he or she can- 
not accomplish independently. 

3. Assess prospective caregivers' 
ability to anticipate and fulfill 
client's unmet needs. Provide 
information to assist caregivers 
with this responsibility. Ensure 
that caregivers are aware of avail- 
able community support systems 
from which they may seek assist- 
ance when required. Examples 
include adult day-care centers, 
housekeeping and homemaker 
services, respite-care services, or 
the local chapter of a national 
support organization: 

a. For Parkinson's disease 

National Parkinson 
Foundation, Inc. 
1501 NW 9th Ave. 
Miami, FL 33136-1494 

3 . To ensure provision and continu- 
ity of client care. 

b. For Alzheimer's disease 

Alzheimer's Association 

225 N. Michigan Ave., 

FL 17 

Chicago, IL 60601-7633 


http ://www. alz. org 

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Box 12-3 Validation Therapy 

Some people believe it is not helpful (and sometimes even 
cruel) to insist that a person with moderate to severe de- 
mentia continually try to grasp what we know as the "real 
world." Allen (2000) states: 

There is no successful alternative but to accept whatever the 
dementia person claims as their reality, no matter how un- 
true it is to us. There is no successful way to "force" a person 
with dementia to join the "real" world. The most frustrated 
caregivers are the ones who do not accept this simple fact: the 
world of dementia is defined by the dementia victim. 

Validation therapy (VT) was originated by Naomi Feil, a 
gerontological social worker, who describes the process 
as "communicating with a disoriented elderly person by 
validating and respecting their feelings in whatever time or 
place is real to them at the time, even though this may not 
correspond with our 'here and now' reality" (Day, 2003). 
Feil suggests that the validation principle is truthful to the 
person with dementia because people live on several levels 
of awareness (Feil, 2007). She suggests that if an individual 
asks to see his or her spouse, and the spouse has been dead 
for many years, on some level of awareness that person 
knows the truth. To keep reminding the person that the 
spouse is dead may only serve to cause repeated episodes 
of grief and distress, as he or she receives the information 
"anew" each time it is presented (Allen, 2000). 

Validation therapy validates the feelings and emotions of 
the person with dementia. It often also integrates redirec- 
tion techniques. Allen (2000) states, "The key is to 'agree' 
with what they want, but by conversation and 'steering,' 
get them to do something else without them realizing they 
are actually being redirected. This is both validation and 
redirection therapy." 


Mrs. W (agitated): "That old lady stole my watch! I know 

she did. She goes into people's rooms and takes our things. 

We call her 'sticky fingers!'" 
Nurse: "That watch is very important to you. Have you 

looked around the room for it?" 
Mrs. W: "My husband gave it to me. He will be so upset 

that it is gone. I'm afraid to tell him." 

Nurse: "I'm sure you miss your husband very much. Tell 

me what it was like when you were together. What kinds 

of things did you do for fun?" 
Mrs. W: "We did a lot of traveling. To Italy, and England, 

and France. We ate wonderful food." 
Nurse: "Speaking of food, it is lunchtime, and I will walk 

with you to the dining room." 
Mrs. W: "Yes, I'm getting really hungry." 

In this situation, the nurse validated Mrs. W's feelings 
about not being able to find her watch. She did not deny 
that it had been stolen, nor did she remind Mrs. W that her 
husband was deceased. {Remember: a concept ofVTis that on 
some level, Mrs. W knows that her husband is dead.) The nurse 
validated the emotions Mrs. W was feeling about missing 
her husband. She brought up special times that Mrs. W and 
her husband had spent together, which served to elevate 
her mood and self-esteem. And lastly, she redirected Mrs. 
W to the dining room to have her lunch. (The watch was 
eventually found in Mrs. W's medicine cabinet, where she 
had hidden it for safekeeping.) 

Feil (2007) presents another example: 

When a resident asks for his wife, who is dead, caregiv- 
ers reply, "SheHl be here to see you later." The resident may 
not remember much, but he clings to that statement. He 
continues to ask for his wife on a daily basis, and the care- 
givers continue to lie. Eventually, he loses trust in the care- 
givers, knowing that what they say is not true. With VT, 
the caregivers would encourage the resident to talk about his 
wife. They would validate his emotions and encourage him 
to express his needs, accepting the fact that there is a rea- 
son behind his behavior. He has not simply "forgotten that 
his wife died;" he needs to grieve for her. This is unfinished 
business. When the emotion is expressed and someone listens 
with empathy, it is relieved. The old man no longer needs to 
search for his wife. He feels safe with the caregiver, whom 
he trusts. He always knew on a deep level of awareness that 
his wife had died. (pp. 3, 4) 

3. Is the client able to fulfill basic needs? Have 
those needs unmet by the client been fulfilled by 

4. Is confusion minimized by familiar objects and 
structured, routine schedule of activities? 

5. Do the prospective caregivers have information re- 
garding the progression of the client's illness? 

6. Do caregivers have information regarding where to 
go for assistance and support in the care of their 
loved one? 

7. Have the prospective caregivers received instruc- 
tion in how to promote the client's safety, minimize 
confusion and disorientation, and cope with difficult 

client behaviors (e.g., hostility, anger, depression, 


The first step in the treatment of delirium is the de- 
termination and correction of the underlying causes. 
Additional attention must be given to fluid and elec- 
trolyte status, hypoxia, anoxia, and diabetic problems. 
Staff members should remain with the client at all 
times to monitor behavior and provide reorientation 

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Impairments in 
cognitive and 


Memory deficits 
Inaccurate inter- 
pretation of the 


Unable to fulfill 
activities of daily 

Nsg. Dx: 

Risk for Trauma 

Nsg. Dx: 

Disturbed Thought Processes 

Nsg. Dx: 

Self-Care Deficit 

Nursing Actions: 

• Arrange furniture to 
facilitate movement 

• Keep bed in low position 

• Assist with ambulation 

• Provide nightlight 

• Provide safe place for 

• Keep level or stimuli in the 
environment low 

Nursing Actions: 

• Display clocks and calendars 
with large numbers 

• Put signs on doors to 
identify specific rooms 

• Allow client to have personal 

• Speak slowly and distinctly, 
in face-to-face contact 

• Distract from delusions and 

Medical RX: 
Aricept 5 mg q HS 

Nursing Actions: 

• Allow time to do tasks 

• Provide step-by-step 

• Provide simple, structured 

• Provide for consistency 
of caregivers 

• Anticipate and fulfill unmet 

FIGURE 12-3 Concept map care plan. 

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Box 12-4 Topics for Client/Family Education 
Related to Cognitive Disorders 

1 . Nature of the illness 

a. Possible causes 

b. What to expect 

c. Symptoms 

2. Management of the illness 

a. Ways to ensure client safety 

b. How to maintain reality orientation 

c. Providing assistance with ADLs 

d. Nutritional information 

e. Difficult behaviors 

f. Medication administration 

g. Matters related to hygiene and toileting 

3 . Support services 

a. Financial assistance 

b. Legal assistance 

c. Caregiver support groups 

d. Respite care 

e. Home health care 

and assurance. The room should maintain a low level 
of stimuli. 

Some physicians prefer not to prescribe medica- 
tions for the delirious client, reasoning that additional 
agents may only compound the syndrome of brain dys- 
function. However, the agitation and aggression dem- 
onstrated by the delirious client may require chemical 
and/or mechanical restraint. Choice of specific thera- 
py is made with consideration for the client's clinical 
condition and the underlying cause of the delirium. 
Low-dose neuroleptics are the pharmacological treat- 
ment of choice in most cases (Trzepacz et al, 2006). 
A benzodiazepine (e.g., lorazepam) is commonly used 
when the etiology is substance withdrawal (Eisendrath 
& Lichtmacher, 2009). 


Once a definitive diagnosis of dementia has been 
made, a primary consideration in the treatment of the 
disorder is the etiology. Focus must be directed to the 
identification and resolution of potentially reversible 
processes. Sadock and Sadock (2007) state: 

Once dementia is diagnosed, patients must undergo a 
complete medical and neurological workup, because 
10 to 15 percent of all patients with dementia have a 
potentially reversible condition if treatment is initi- 
ated before permanent brain damage occurs. [Causes 
of potentially reversible dementia include] hypothy- 
roidism, normal pressure hydrocephalus, and brain 
tumors, (p. 340) 

The need for general supportive care, with provi- 
sions for security, stimulation, patience, and nutrition, 

has been recognized and accepted. A number of phar- 
maceutical agents have been tried, with varying degrees 
of success, in the treatment of clients with dementia. 
Some of these drugs are described in the following sec- 
tions according to symptomatology for which they are 
indicated. A summary of medications for clients with 
dementia is provided in Table 12-4. 

Cognitive Impairment 

The cholinesterase inhibitor physostigmine (Antiliri- 
um) has been shown to enhance cognitive functioning 
in individuals with mild to moderate AD, although its 
short half-life makes it less desirable than the newer 
medications (Coelho Filho & Birks, 2001). 

Other cholinesterase inhibitors are also being used 
for treatment of mild to moderate cognitive impair- 
ment in AD. Some of the clinical manifestations of 
AD are thought to be the result of a deficiency of the 
neurotransmitter acetylcholine. In the brain, acetyl- 
choline is inactivated by the enzyme acetylcholineste- 
rase. Tacrine (Cognex), donepezil (Aricept), rivastigmine 
(Exelon), and galantamine (Razadyne) act by inhibiting 
acetylcholinesterase, which slows the degradation of 
acetylcholine, thereby increasing concentrations of the 
neurotransmitter in the cerebral cortex. Because their 
action relies on functionally intact cholinergic neurons, 
the effects of these medications may lessen as the dis- 
ease process advances. There is no evidence that these 
medications alter the course of the underlying dement- 
ing process. 

Another medication, an N-methyl-D-aspartate 
(NMDA) receptor antagonist, was approved by the 
U.S. Food and Drug Administration (FDA) in 2003. 
The medication, memantine (Namenda), was ap- 
proved for the treatment of moderate to severe AD. 
High levels of glutamate in the brains of AD patients 
are thought to contribute to the symptomatology and 
decline in functionality. These high levels are caused 
by a dysfunction in glutamate transmission. In normal 
neurotransmission, glutamate plays an essential role 
in learning and memory by triggering NMDA recep- 
tors to allow a controlled amount of calcium to flow 
into a nerve cell (Alzheimer's Association, 2007a). This 
creates the appropriate environment for information 
processing. In AD, there is a sustained release of gluta- 
mate, which results in a continuous influx of calcium 
into the nerve cells. This increased intracellular cal- 
cium concentration ultimately leads to disruption and 
death of the neurons. Memantine may protect cells 
against excess glutamate by partially blocking NMDA 
receptors. Memantine has shown in clinical trials to 
be effective in improving cognitive function and the 

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Selected Medications Used in the Treatment of Clients With Dementia 

Daily Dosage 

Common Side 



For Treatment of 

Range (mg) 


Tacrine (Cognex) 

Cholinesterase inhibitor 

Cognitive impairment 


Dizziness, headache, 
GI upset, elevated 

Donepezil (Aricept) 

Cholinesterase inhibitor 

Cognitive impairment 


Insomnia, dizziness, GI 
upset, headache 

Rivastigmine (Exelon) 

Cholinesterase inhibitor 

Cognitive impairment 


Dizziness, headache, 
GI upset, fatigue, 


Cholinesterase inhibitor 

Cognitive impairment 


Dizziness, headache, GI 



Memantine (Namenda) 

NMDA receptor 

Cognitive impairment 


Dizziness, headache, 



Agitation, aggres- 

1-4 (Increase dosage 

Agitation, headache, 


sion, hallucinations, 
thought disturbances, 


insomnia, extrapy- 
ramidal symptoms 

Olanzapine* (Zyprexa) 


Agitation, aggres- 

5 (Increase dosage 

Hypotension, dizziness, 

sion, hallucinations, 


sedation, constipa- 

thought disturbances, 

tion, weight gain, dry 



Quetiapine* (Seroquel) 


Agitation, aggres- 

Initial dose 2 5 

Hypotension, tachy- 

sion, hallucinations, 

(Titrate slowly) 

cardia, dizziness, 

thought disturbances, 

drowsiness, headache, 


constipation, dry 

Haloperidol* (Haldol) 


Agitation, aggres- 

1-4 (Increase dosage 

Dry mouth, blurred 

sion, hallucinations, 


vision, orthostatic 

thought disturbances, 

hypotension, extrapy- 


ramidal symptoms, 

Sertraline (Zoloft) 

Antidepressant (SSRI) 



Fatigue, insomnia, 
sedation, GI upset, 
headache, dizziness 

Paroxetine (Paxil) 

Antidepressant (SSRI) 



Dizziness, headache, in- 
somnia, somnolence, 
GI upset 

Nortriptyline (Pamelor) 

Antidepressant (tricy- 



Anticholinergic, ortho- 
static hypotension, 
sedation, arrhythmia 

Lorazepam (Ativan) 

Antianxiety (benzodi- 



Drowsiness, dizziness, 
GI upset, hypoten- 
sion, tolerance, 

Oxazepam (Serax) 

Antianxiety (benzodi- 



Drowsiness, dizziness, 
GI upset, hypoten- 
sion, tolerance, 

Temazepam (Restoril) 

Sedative-hypnotic (ben- 



Drowsiness, dizziness, 
GI upset, hypoten- 
sion, tolerance, 

Zolpidem (Ambien) 

Sedative-hypnotic (non- 



Headache, drowsiness, 
dizziness, GI upset 


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Table 12-4 

Selected Medications Used in theTreatment of Clients With Dementia— cont'd 

Daily Dosage 

Common Side 



For Treatment of 

Range (mg) 


Zaleplon (Sonata) 

Sedative-hypnotic (non- 



Headache, drowsiness, 
dizziness, GI upset 

Eszopiclone (Lunesta) 

Sedative-hypnotic (non- 



Headache, drowsiness, 
dizziness, GI upset, 
unpleasant taste 

Trazodone (Desyrel) 

Antidepressant (hetero- 

Depression and 


Dizziness, drowsiness, 



dry mouth, blurred 
vision, GI upset 

Mirtazapine (Remeron) 

Antidepressant (tetra- 

Depression and 


Somnolence, dry 



mouth, constipation, 
increased appetite 

* Although clinicians may still prescribe these drugs in low-risk patients, no antipsychotics have been approved by the FDA for 
the treatment of patients with dementia-related psychosis. All antipsychotics include black-box warnings about increased risk 
of death in elderly dementia patients. 

GI, gastrointestinal. 

ability to perform ADLs in clients with moderate to 
severe AD. Although it does not stop or reverse the ef- 
fects of the disease, it has been shown to slow down the 
progression of the decline in cognition and function 
(Salloway & Correia, 2009). Because memantine's ac- 
tion differs from that of the cholinesterase inhibitors, 
consideration is being given to coadministering these 
medications. Ongoing research is revealing a greater 
improvement in cognitive function, ADLs, behavior, 
and clinical global status in clients who are adminis- 
tered a combination of memantine and a cholineste- 
rase inhibitor than those administered either drug 
alone (Diamond, 2008). 

Agitation, Aggression, Hallucinations, 
Thought Disturbances, and Wandering 

Historically, physicians have prescribed antipsychotic 
medications to control agitation, aggression, hallucina- 
tions, thought disturbances, and wandering in clients 
with dementia. The newer antipsychotic medications, 
such as risperidone, olanzapine, quetiapine, and ziprasi- 
done, were often favored because of their lessened pro- 
pensity to cause anticholinergic and extrapyramidal 
side effects. In 2005, however, following review of a 
number of studies, the FDA ordered black-box warn- 
ings on drug labels of all the atypical antipsychotics, 
noting that the drugs are associated with an increased 
risk of death in elderly patients with psychotic behav- 
iors associated with dementia. Most of the deaths ap- 
peared to be cardiovascular related. In July 2008, based 
on the results of several studies, the FDA extended this 

warning to include all first- generation antipsychotics 
as well, such as haloperidol and perphenazine (Yan, 
2008). This poses a clinical dilemma for physicians who 
have found these medications to be helpful to their cli- 
ents, and some have chosen to continue to use them 
in clients without significant cerebrovascular disease, 
in whom previous behavioral programs have failed, 
and with consent from relatives or guardians who are 
clearly aware of the risks and benefits. 

Anticholinergic Effects 

Many antipsychotic, antidepressant, and antihistamine 
medications produce anticholinergic side effects, which 
include confusion, blurred vision, constipation, dry 
mouth, dizziness, and difficulty urinating. Older people, 
and especially those with dementia, are particularly sen- 
sitive to these effects. Beers and Jones (2004) explain this 
phenomenon as follows: 

Older people are more likely to experience anticholin- 
ergic effects because as people age, the body produces 
less acetylcholine. Also, cells in many parts of the body 
(such as the digestive tract) have fewer sites where 
acetylcholine can attach to them. Thus, the acetylcho- 
line produced is less likely to have an effect, and the 
effect of anticholinergic drugs is greater, (p. 48) 


It is estimated that up to 40 percent of people with 
Alzheimer's disease also suffer from major depression 
(Alzheimer's Association, 2007b). Recognizing the 
symptoms of depression in these individuals is often 

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a challenge. Depression — which affects thinking, 
memory, sleep, appetite, and interferes with daily 
life — is sometimes difficult to distinguish from demen- 
tia. Clearly, the existence of depression in the client 
with dementia complicates and worsens the individu- 
al's functioning. 

Antidepressant medication is sometimes used in 
treatment of depression in dementia. The selective se- 
rotonin reuptake inhibitors (SSRIs) are considered by 
many to be the first-line drug treatment for depression 
in the elderly because of their favorable side effect pro- 
file. Although still used by some physicians, tricyclic 
antidepressants are often avoided because of cardiac and 
anticholinergic side effects. Trazodone may be a good 
choice, used at bedtime, for depression and insomnia. 
Dopaminergic agents (e.g., methylphenidate, amanta- 
dine, bromocriptine, bupropion) may be helpful in the 
treatment of severe apathy (Rabins et al, 2006). 

Not only is depression common in AD, but research 
has recently suggested that it may be a risk factor for 
the disease (Geerlings et al, 2008). This study found 
that individuals with a history of depression, particu- 
larly those with onset before age 60, had a 2.5 times 
greater risk of developing AD than people who had 
not suffered from depression. The authors suggest 
that further studies are required to understand the re- 
lationship between depression and AD. It is not com- 
pletely understood whether depression contributes to 
the development of AD or whether another unknown 
factor is involved in the etiology of both depression 
and dementia. 


The progressive loss of mental functioning is a signifi- 
cant source of anxiety in the early stages of dementia. 
It is important that clients be encouraged to verbalize 
their feelings and fears associated with this loss. These 
interventions may be useful in reducing the anxiety of 
clients with dementia. 

Antianxiety medications may be helpful but should 
not be used routinely or for prolonged periods. The 
least toxic and most effective of the antianxiety medi- 
cations are the benzodiazepines. Examples include 
diazepam (Valium), chlordiazepoxide (Librium), al- 
prazolam (Xanax), lorazepam (Ativan), and oxazepam 
(Serax). The drugs with shorter half-lives (e.g., lo- 
razepam and oxazepam) are preferred to those longer- 
acting medications (e.g., diazepam), which promote a 
higher risk of oversedation and falls. Barbiturates are 
not appropriate as antianxiety agents because they fre- 
quently induce confusion and paradoxical excitement 
in elderly individuals. 

Sleep Disturbances 

Sleep problems are common in clients with dementia 
and often intensify as the disease progresses. Wakeful- 
ness and nighttime wandering create much distress and 
anguish in family members who are charged with pro- 
tection of their loved one. Indeed, sleep disturbances 
are among the problems that most frequently initiate 
the need for placement of the client in a long-term 
care facility. 

Some physicians treat sleep problems with sedative- 
hypnotic medications. The benzodiazepines may be use- 
ful for some clients but are indicated for relatively brief 
periods only. Examples include flurazepam (Dalmane), 
temazepam (Restoril), and triazolam (Halcion). Day- 
time sedation and cognitive impairment, in addition to 
paradoxical agitation in elderly clients, are of particular 
concern with these medications (Beers & Jones, 2004). 
The nonbenzodiazepine sedative-hypnotics Zolpidem 
(Ambien), zaleplon (Sonata), eszopiclone (Lunesta), and 
ramelteon (Rozerem) and the antidepressants trazodone 
(Desyrel) and mirtazapine (Remeron), are also pre- 
scribed. Daytime sedation may also be a problem with 
these medications. As previously stated, barbiturates 
should not be used in elderly clients. Sleep problems are 
usually ongoing, and most clinicians prefer to use med- 
ications only to help an individual through a short- 
term stressful situation. Rising at the same time each 
morning; minimizing daytime sleep; participating in 
regular physical exercise (but no later than 4 hours 
before bedtime); getting proper nutrition; avoid- 
ing alcohol, caffeine, and nicotine; and retiring at 
the same time each night are behavioral approaches 
to sleep problems that may eliminate the need 
for sleep aids, particularly in the early stages of 
dementia. Because of the tremendous potential for 
adverse drug reactions in the elderly, many of whom 
are already taking multiple medications, pharmaco- 
logical treatment of insomnia should be considered 
only after attempts at nonpharmacological strategies 
have failed. 


Cognitive disorders constitute a large and growing 

public health concern. 

Cognitive disorders include delirium, dementia, and 

amnestic disorders. 

A delirium is a disturbance of consciousness and a 

change in cognition that develop rapidly over a short 

period. Level of consciousness is often affected, 

and psychomotor activity may fluctuate between 

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Carmen is an 81-year-old widow who has lived in 
the same small town, in the same house that she 
shared with her husband until his death 16 years 
ago. She and her husband raised two daughters, 
Joan and Nancy, who have been living with their 
husbands in a large city about 2 hours away from 
Carmen. They have always visited Carmen every 
1 or 2 months. She has four grown grandchildren 
who live in distant states and who see their grand- 
mother on holidays. 

About a year ago, Carmen's daughters began 
to receive reports from friends and other family 
members about incidents in which Carmen was 
becoming forgetful (e.g., forgetting to go to a cous- 
in's birthday party, taking a wrong turn and getting 
lost on the way to a niece's house [where she had 
driven many times], returning to church to search 
for something she thought she "had forgotten," [al- 
though she could not explain what it was], sending 
birthday gifts to people when it was not their birth- 
day). During routine visits, the elder daughter, Joan, 
found bills left unpaid, sometimes months overdue. 
Housekeepers and yard workers reported to Joan 
that Carmen would forget she had paid them, and 
try to pay them again . . . and sometimes a third 
time. She became very confused when she would 
attempt to fill her weekly pillboxes, a task she had 
completed in the past without difficulty. Hundreds 
of dollars would disappear from her wallet, and she 
could not tell Joan what happened to it. 

Joan and her husband subsequently moved to 
the small town where Carmen lived. They bought a 
home, and Joan visited her mother every day, took 
care of finances, and ensured that Carmen took her 
daily medications, although Joan worked in a job 
that required occasional out of town travel. As the 
months progressed, Carmen's cognitive abilities 
deteriorated. She burned food on the stove, left the 
house with the broiler-oven on, forgot to take her 
medication, got lost while driving her car, missed 
appointments, and forgot the names of her neigh- 
bors whom she had known for many years. She 
began to lose weight because she began forgetting 
to eat her meals. 

Carmen was evaluated by a neurologist, who 
diagnosed her with Dementia of the Alzheimer's 
Type, Late Onset. Because they believed that 
Carmen needed 24-hour care, Joan and Nancy 
made the painful decision to place Carmen in long- 
term care. In the nursing home, her condition has 
continued to deteriorate. Carmen wanders up and 
down the halls (day and night), and she has fallen 
twice, once while attempting to get out of bed. She 

requires assistance to shower and dress and has 
become incontinent of urine. The nurses found her 
attempting to leave the building, saying, Tm going 
across the street to visit my daughter." One morn- 
ing at breakfast she appeared in her pajamas in the 
communal dining room, not realizing that she had 
not dressed. She is unable to form new memories, 
and sometimes uses confabulation to fill in the 
blanks. She asks the same questions repeatedly, 
sometimes struggling for the right word. She can 
no longer provide the correct names of items in her 
environment. She has no concept of time. 

Joan visits Carmen daily, and Nancy visits weekly, 
each offering support to the other in person and by 
phone. Carmen always seems pleased to see them, 
but can no longer call either of them by name. They 
are unsure if she knows who they are. 


From the assessment data, the nurse develops the 
following nursing diagnoses for Carmen. 

1. Risk for trauma related to impairments in 
cognitive and psychomotor functioning; wan- 
dering; falls 

a. Outcome criteria: Carmen will remain 
injury free during her nursing home stay. 

b. Short-term goals: 

• Carmen will not fall while wandering the 

• Carmen will not fall out of bed. 

2. Disturbed thought processes related to cer- 
ebral degeneration evidenced by disorientation, 
confusion, and memory deficits 

a. Outcome criteria: Carmen will maintain 
reality orientation to the best of her cogni- 
tive ability. 

b. Short-term goals: 

• Carmen will be able to find her room. 

• Carmen will be able to communicate her 
needs to staff. 

3. Self-care deficit related to cognitive impair- 
ments, disorientation, confusion, and memory 

a. Outcome criteria: Carmen will accomplish 
activities of daily living (ADLs) to the best of 
her ability. 

b. Short-term goals: 

• Carmen will assist with dressing herself. 

• Carmen will cooperate with trips to the 

• Carmen will wash herself in the shower, 
with help from the nurse. 

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Risk for Trauma 

The following nursing interventions may be imple- 
mented in an effort to ensure client safety: 

1. Arrange the furniture in Carmen's room so that 
it will accommodate her moving around freely. 

2. Store frequently used items within her easy 

3. Provide a "low bed/' or possibly move her mat- 
tress from the bed to the floor, to prevent falls 
from bed. 

4. Attach a bed alarm to alert the nurse's station 
when Carmen has alighted from her bed. 

5. Keep a dim light on in her room at night. 

6. During the day and evening, provide a well- 
lighted area where Carmen can safely wander. 

7. Ensure that all outside doors are electronically 

8. Play soft music and maintain a low level of 
stimuli in the environment. 

Disturbed Thought Processes 

The following nursing interventions may be imple- 
mented to help maintain orientation and aid in 
memory and recognition: 

1. Use clocks and calendars with large numbers 
that are easy to read. 

2. Put a sign on Carmen's door with her name 
on it, and hang a personal item of hers on the 

3. Ask Joan to bring some of Carmen's personal 
items for her room, even a favorite comfy chair, 
if possible. Ask also for some old photograph 
albums if they are available. 

4. Keep staff and caregivers to a minimum to 
promote familiarity. 

5. Speak slowly and clearly while looking into 
client's face. 

6. Use reminiscence therapy with Carmen. Ask her 
to share happy times from her life with you. 
This technique helps decrease depression and 
boost self-esteem. 

7. Mention the date and time in casual conversa- 
tion. Refer to "spring rain," "summer flowers," 
"fall leaves." Emphasize holidays. 

8. Correct misperceptions gently and matter-of- 
factly, and focus on real events and real 
people if false ideas should occur. Validate 

her feelings associated with current and past 
life situations. 
9. Monitor for medication side effects, because 
toxic effects from certain medications can in- 
tensify altered thought processes. 

Self-Care Deficit 

The following nursing interventions may be imple- 
mented to ensure that all Carmen's needs are 

1. Assess what Carmen can do independently and 
with what she needs assistance. 

2. Allow plenty of time for her to accomplish tasks 
that are within her ability. Clothing with easy 
removal or replacement, such as Velcro, facili- 
tates independence. 

3. Provide guidance and support for independent 
actions by talking her through tasks one step at 
a time. 

4. Provide a structured schedule of activities that 
does not change from day to day. 

5. Ensure that Carmen has snacks between meals. 

6. Take Carmen to the bathroom regularly (ac- 
cording to her usual pattern, e.g., after meals, 
before bedtime, on arising) 

7. To minimize nighttime wetness, offer fluid 
every 2 hours during the day and restrict fluid 
after 6:00 p.m. 

8. To promote more restful nighttime sleep (and 
less wandering at night), reduce naps during 
late afternoon and encourage sitting exercises, 
walking, and ball toss. Carbohydrate snacks at 
bedtime may also be helpful. 


The outcome criteria identified for Carmen have 
been met. She has experienced no injury. She has 
not fallen out of bed. She continues to wander in 
a safe area. She can find her room by herself, but 
occasionally requires some assistance when she is 
anxious and more confused. She has some difficul- 
ty communicating her needs to the staff, but those 
who work with her on a consistent basis are able 
to anticipate her needs. All ADLs are being fulfilled, 
and Carmen assists with dressing and grooming, 
accomplishing about half on her own. Nighttime 
wandering has been minimized. Soft bedtime mu- 
sic helps to relax her. 

2338_Ch12_231-265.indd 259 

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agitated purposeless movements and a vegetative 
state resembling catatonic stupor. 
The symptoms of delirium usually begin quite 
abruptly and often are reversible and brief. 
Delirium may be caused by a general medical condi- 
tion, substance intoxication or withdrawal, or inges- 
tion of a medication or toxin. 

Dementia is a syndrome of acquired, persistent in- 
tellectual impairment with compromised function in 
multiple spheres of mental activity, such as memory, 
language, visuospatial skills, emotion or personality, 
and cognition. 

Symptoms of dementia are insidious and develop 
slowly over time. In most clients, dementia runs a 
progressive, irreversible course. 
Dementia may be caused by genetics, cardiovascu- 
lar disease, infections, neurophysiological disorders, 
and other general medical conditions. 
Amnestic disorders are characterized by an inability 
to learn new information despite normal attention 
and an inability to recall previously learned infor- 
mation. Remote past events are often more easily 
recalled than recent ones. 

The onset of amnestic symptoms may be acute or 
insidious, depending on the pathological process 

causing the disorder. Duration and course of the ill- 
ness may be quite variable and are also correlated 
with extent and severity of the cause. 
Nursing care of the client with a cognitive disor- 
der is presented around the six steps of the nursing 

Objectives of care for the client experiencing an 
acute syndrome are aimed at eliminating the eti- 
ology, promoting client safety, and a return to the 
highest possible level of functioning. 
Objectives of care for the client experiencing a 
chronic, progressive disorder are aimed at preserv- 
ing the dignity of the individual, promoting decel- 
eration of the symptoms, and maximizing functional 

Nursing interventions are also directed toward help- 
ing the client's family or primary caregivers learn 
about a chronic, progressive cognitive disorder. 
Education is provided about the disease process, ex- 
pectations of client behavioral changes, methods for 
facilitating care, and sources of assistance and sup- 
port as they struggle, both physically and emotion- 
ally, with the demands brought on by a disease proc- 
ess that is slowly taking their loved one away from 

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Self-Examination/Learning Exercise 

Select the answer that is most appropriate for each of the following questions. 

1 . An example of a treatable (reversible) form of dementia is one that is caused by which of the 
following? Select all that apply. 

a. Multiple sclerosis 

b. Multiple small brain infarcts 

c. Electrolyte imbalances 

d. HIV disease 

e. Folate deficiency 

2. Mrs. G has been diagnosed with Dementia of the Alzheimer's Type. The cause of this disorder 
which of the following? 

a. Multiple small brain infarcts 

b. Chronic alcohol abuse 

c. Cerebral abscess 

d. Unknown 

3 . Mrs. G has been diagnosed with Dementia of the Alzheimer's Type. The primary nursing 
intervention in working with Mrs. G is which of the following? 

a. Ensuring that she receives food she likes, to prevent hunger 

b. Ensuring that the environment is safe, to prevent injury 

c. Ensuring that she meets the other patients, to prevent social isolation 

d. Ensuring that she takes care of her own ADLs, to prevent dependence 

4. Which of the following medications have been indicated for improvement in cognitive functioning 
in mild to moderate Alzheimer's disease? Select all that apply. 

a. Donepezil (Aricept) 

b. Rivastigmine (Exelon) 

c. Risperidone (Risperdal) 

d. Sertraline (Zoloft) 

e. Tacrine (Cognex) 

5. Mrs. G, who has Alzheimer's disease, says to the nurse, "I have a date tonight. I always have a date 
on Christmas." Which of the following is the most appropriate response? 

a. "Don't be silly. It's not Christmas, Mrs. G." 

b. "Today is Tuesday, Oct. 21, Mrs. G. We will have supper soon, and then your daughter will 
come to visit." 

c. "Who is your date with, Mrs. G?" 

d. "I think you need some more medication, Mrs. G. I'll bring it to you now." 

6. In addition to disturbances in cognition and orientation, individuals with Alzheimer's disease may 
also show changes in which of the following? Select all that apply. 

a. Personality 

b. Vision 

c. Speech 

d. Hearing 

e. Mobility 

2338_Ch12_231-265.indd 261 

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7. Mrs. G, who has Alzheimer's disease, has trouble sleeping and wanders around at night. Which of 
the following nursing actions would be best to promote sleep in Mrs. G? 

a. Ask the doctor to prescribe flurazepam (Dalmane). 

b. Ensure that Mrs. G gets an afternoon nap so she will not be overtired at bedtime. 

c. Make Mrs. G a cup of tea with honey before bedtime. 

d. Ensure that Mrs. G gets regular physical exercise during the day. 

8. The night nurse finds Mrs. G, a client with Alzheimer's disease, wandering the hallway at 4 a.m. 
and trying to open the door to the side yard. Which statement by the nurse probably reflects the 
most accurate assessment of the situation? 

a. "That door leads out to the patio, Mrs. G. It's nighttime. You don't want to go outside now." 

b. "You look confused, Mrs. G. What is bothering you?" 

c. "This is the patio door, Mrs. G. Are you looking for the bathroom?" 

d. "Are you lonely? Perhaps you'd like to go back to your room and talk for a while." 

9. A client says to the nurse: "I read an article about Alzheimer's, and it said the disease is hereditary. 
My mother has Alzheimer's disease. Does that mean I'll get it when I'm old?" The nurse bases 
her response on the knowledge that which of the following factors is not associated with increased 
incidence of dementia of the Alzheimer's type? 

a. Multiple small strokes 

b. Family history of Alzheimer's disease 

c. Head trauma 

d. Advanced age 

10. Mr. Stone is a client in the hospital with a diagnosis of Vascular Dementia. In explaining this 
disorder to Mr. Stone's family, which of the following statements by the nurse is correct? 

a. "He will probably live longer than if his dementia was of the Alzheimer's type." 

b. "Vascular dementia shows stepwise progression. This is why he sometimes seems okay." 

c. "Vascular dementia is caused by plaques and tangles that form in the brain." 

d. "The cause of vascular dementia is unknown." 

1 1 . Which of the following interventions is most appropriate in helping a client with Alzheimer's 
disease with her ADLs? Select all that apply. 

a. Perform ADLs for her while she is in the hospital 

b. Provide her with a written list of activities she is expected to perform 

c. Assist her with step-by-step instructions 

d. Tell her that if her morning care is not completed by 9:00 a.m., it will be performed for her by 
the nurse's aide so that she can attend group therapy. 

e. Encourage her and give her plenty of time to perform as many of her ADLs as possible 


2338_Ch12_231-265.indd 262 

8/31/10 6:00:44 PM 


TestYour Critical Thinking Skills 

Joe, a 62 -year-old accountant, began having difficulty re- 
membering details necessary to perform his job. He was 
also having trouble at home, failing to keep his finances 
straight, and forgetting to pay bills. It became increasingly 
difficult for him to function properly at work, and eventu- 
ally he was forced to retire. Cognitive deterioration con- 
tinued, and behavioral problems soon began. He became 
stubborn, verbally and physically abusive, and suspicious of 
most everyone in his environment. His wife and son con- 
vinced him to see a physician, who recommended hospi- 
talization for testing. 

At Joe's initial evaluation, he was fully alert and cooperative 
but obviously anxious and fidgety He thought he was at his 
accounting office, and he could not state what year it was. He 
could not say the names of his parents or siblings, nor did he 

know who was the current president of the United States. 
He could not perform simple arithmetic calculations, write 
a proper sentence, or copy a drawing. He interpreted prov- 
erbs concretely and had difficulty stating similarities be- 
tween related objects. 

Laboratory serum studies revealed no abnormalities, 
but a CT scan showed marked cortical atrophy. The phy- 
sician's diagnosis was Dementia of the Alzheimer's Type, 
Early Onset. 

Answer the following questions related to Joe. 

1 . Identify the pertinent assessment data from which nurs- 
ing care will be devised. 

2. What is the primary nursing diagnosis for Joe? 

3. How would outcomes be identified? 


A model of consequences of need-driven, dementia- 
compromised behavior. (2005). Journal of Nursing Scholar- 
ship, 57(2), 134-140. Kovach, C.R., Noonan, P.E., Schlidt, 
A.M.,& Wells, T 

Description of the Study: Need-driven, dementia- 
compromised behavior (NDB) occurs because the 
caregiver is unable to comprehend needs, and the person 
with dementia cannot make needs known. The behaviors 
are viewed as an attempt on the part of the person with 
dementia to communicate a need and as a symptom 
that the need is not being met. The authors extend the 
primary need model to encompass secondary needs when 
primary needs go unresolved. From an extensive literature 
review, the authors proposed a framework for improving 
understanding of the person with dementia and the 
consequences of behavioral symptoms and unmet needs. 

Results of the Study: The experiences of people with 
dementia who have unmet needs is described as having 
"cascading effects." In people with dementia, basic 
needs (e.g., thirst/need for fluid) result in primary NDB 
(e.g., restlessness/repetitive movements), which, if left 
unmet, may result in the negative outcome of constipation 
and abdominal discomfort. This need for relief may lead 

to the secondary NDB of aggression. The authors state, 
"Secondary NDBs are iatrogenic outcomes of these 
cascading effects and the response of a vulnerable person to 
the recurrent and unpredictable stress of treatment targeted 
inappropriately or care providers who dismiss the NDB 
communication." Common problematic behaviors that 
may be associated with unmet needs include resistiveness 
to care, verbal complaining, restlessness, facial grimacing, 
aggression, crying, moaning, calling out, exiting behavior, 
tense body parts, and rubbing or holding a body part. Unmet 
needs may also influence affective status (e.g., depression 
or anxiety), physical status (e.g., immune suppression), and 
acceleration in functional status. 

Implications for Nursing Practice: The authors of this 
study state, "The consequences of need-driven dementia- 
compromised behavior theory indicates that meeting needs 
of people with dementia will moderate the sequence of 
events that leads to negative outcomes." When caregivers 
cannot understand primary NDBs, they cannot provide 
anticipatory care. The anticipation and fulfillment of 
clients' needs is necessary to decrease the prevalence and 
severity of new unmet needs, thereby positively influencing 
comfort and quality of life for people with dementia. 

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Rabins, P., Bland, W, Bright-Long, L., Cohen, E., Katz, I., 

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2# Internet References 

Additional information about Alzheimer's Disease may be 
located at the following websites: 




Information on caregiving can be located at the following 


Additional information about medications to treat Alzheimer's 
disease may be located at the following websites: 





Assignment: Linking Evidence-Based Practice With a Nursing Procedure 
Reality Orientation of Clients With Dementia 

Competency Domain: Evidence-Based Practice 

Learning Objectives: Student will: 

• Locate an evidence-based practice article on a hospital protocol, and compare and contrast this informa- 
tion with the facility's protocol. 

• Identify whether evidence-based practice is utilized with this protocol, and identify barriers or challenges 
with implementing evidence-based practice in the clinical setting. 

Strategy Overview: 

1 . Research the nursing intervention of reality orientation of clients with dementia. Identify the pros and 
cons and ethical issues associated with this intervention (particularly with clients who have advanced 

2. Find an evidence-based practice journal article about the intervention. 

3 . Locate the facility's protocol for reality orientation of clients with dementia. 

4. Compare and contrast the facility's protocol with how unit staff carry out this intervention. If there are 
deviations from the written protocol, what are they and why do the nurses deviate from the written 

5. Compare and contrast the hospital's protocol with the information found in the evidence-based practice 

6. Postconference, summarize the article on evidence-based practice to the clinical group and report 
information gathered throughout the clinical day Discuss any ethical dilemmas associated with the 

7. Write a paper discussing personal reflections and feelings about this intervention. 

Source: Adapted from teaching strategy submitted by Chris Tesch, Instructor, University of South Dakota, Sioux Falls, SD. © 2009 QSEN; 
With permission. 

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H A P T E R 
















Alcoholics Anonymous 

disulfiram (Antabuse) 



dual diagnosis 



esophageal varices 

substitution therapy 


hepatic encephalopathy 

Wernicke's encephalopathy 


Korsakoff's psychosis 







After reading this chapter, the student will be able to: 



1. Define abuse, dependence, intoxication, 
and withdrawal. 

2. Discuss etiological implications for 
substance-related disorders. 

3. Identify symptomatology and use the 
information in assessment of clients with 
various substance-use disorders and 
substance-induced disorders. 


Identify nursing diagnoses common to 
clients with substance-use disorders and 
substance-induced disorders, and select 
appropriate nursing interventions 
for each. 

Identify topics for client and family teach- 
ing relevant to substance-use disorders 
and substance-induced disorders. 

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6. Describe relevant outcome criteria for 
evaluating nursing care of clients with 
substance-use disorders and substance- 
induced disorders. 

7. Describe various modalities relevant to 
treatment of individuals with substance- 
use disorders and substance-induced 


Please read the chapter and answer the following questions. 

1. What are the physical consequences of 
thiamine deficiency in chronic alcohol 

2. Define tolerance as it relates to physical 
dependence on a substance. 

3. Describe two types of toxic reactions that 
can occur with the use of hallucinogens. 

4. What is substitution therapy? 


Substance-related disorders are composed of two groups: 
the substance-use disorders (dependence and abuse) and 
the substance-induced disorders (intoxication, with- 
drawal, delirium, dementia, amnesia, psychosis, mood 
disorder, anxiety disorder, sexual dysfunction, and sleep 
disorders). This chapter discusses dependence, abuse, 
intoxication, and withdrawal. The remainder of the 
substance-induced disorders are included in the chapters 
with which they share symptomatology (e.g., substance- 
induced anxiety disorders are included in Chapter 17). 

Drugs are a pervasive part of our society. Certain 
mood-altering substances are quite socially acceptable 
and are used moderately by many adult Americans. 
They include alcohol, caffeine, and nicotine. Society 
has even developed a relative indifference to an occa- 
sional abuse of these substances, despite documenta- 
tion of their negative impact on health. 

A wide variety of substances are produced for me- 
dicinal purposes. These include central nervous system 
(CNS) stimulants (e.g., amphetamines), CNS depres- 
sants (e.g., sedatives, tranquilizers), as well as numer- 
ous over-the-counter preparations designed to relieve 
nearly every kind of human ailment, real or imagined. 

Some illegal substances have achieved a degree of so- 
cial acceptance by various subcultural groups within our 
society. These drugs, such as marijuana and hashish, are 
by no means harmless, and the long-term effects are still 
being studied. On the other hand, the dangerous effects 
of other illegal substances (e.g., lysergic acid diethyla- 
mide [LSD], phencyclidine, cocaine, and heroin) have 
been well documented. 

This chapter discusses the physical and behavioral 
manifestations and personal and social consequences 
related to the abuse of or dependency on alcohol, oth- 
er CNS depressants, CNS stimulants, opioids, hallu- 
cinogens, and cannabinols. Wide cultural variations in 
attitudes exist regarding substance consumption and 
patterns of use. Substance abuse is especially preva- 
lent among individuals between the ages of 18 and 24. 
Substance-related disorders are diagnosed more com- 
monly in men than in women, but the gender ratios 
vary with the class of the substance (American Psychi- 
atric Association [APA], 2000). 

Nursing care for substance abuse, dependence, in- 
toxication, and withdrawal is presented in the context 
of the six steps of the nursing process. Various medical 
and other treatment modalities are also discussed. 


Substance Abuse 

The Diagnostic and Statistics Manual of Mental Disorders, 
Fourth Edition, Text Revision (DSM-IV-TR) (APA, 2000) 
identifies substance abuse as a maladaptive pattern of 



To use wrongfully or in a harmful way. Improper 
treatment or conduct that may result in injury. 


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substance use manifested by recurrent and significant 
adverse consequences related to repeated use of the 
substance. Substance abuse has also been referred to 
as any use of substances that poses significant hazards 
to health. 

DSM-IV-TR Criteria for Substance 

Substance abuse is described as a maladaptive pattern 
of substance use leading to clinically significant im- 
pairment or distress, as manifested by one (or more) of 
the following, occurring within a 12 -month period: 

1 . Recurrent substance use resulting in a failure to ful- 
fill major role obligations at work, school, or home 
(e.g., repeated absences or poor work performance 
related to substance use; substance-related absenc- 
es, suspensions, or expulsions from school; neglect 
of children or household). 

2 . Recurrent substance use in situations in which it is 
physically hazardous (e.g., driving an automobile 
or operating a machine when impaired by sub- 
stance use). 

3. Recurrent substance-related legal problems (e.g., 
arrests for substance-related disorderly conduct). 

4. Continued substance use despite having persistent 
or recurrent social or interpersonal problems caused 
or exacerbated by the effects of the substance (e.g., 
arguments with spouse about consequences of in- 
toxication, physical fights). 

Substance Dependence 
Physical Dependence 

Physical dependence on a substance is evidenced by 
a cluster of cognitive, behavioral, and physiological 
symptoms indicating that the individual continues use 
of the substance despite significant substance-related 
problems (APA, 2000). As this condition develops, the 
repeated administration of the substance necessitates its 
continued use to prevent the appearance of unpleasant 



A compulsive or chronic requirement. The need is 
so strong as to generate distress (either physical or 
psychological) if left unfulfilled. 

effects characteristic of the withdrawal syndrome asso- 
ciated with that particular drug. The development of 
physical dependence is promoted by the phenomenon 
of tolerance. Tolerance is defined as the need for increas- 
ingly larger or more frequent doses of a substance in 
order to obtain the desired effects originally produced 
by a lower dose. 

Psychological Dependence 

An individual is considered to be psychologically de- 
pendent on a substance when there is an overwhelming 
desire to repeat the use of a particular drug to produce 
pleasure or avoid discomfort. It can be extremely pow- 
erful, producing intense craving for a substance as well 
as its compulsive use. 

DSM-IV-TR Criteria for Substance 

At least three of the following characteristics must be 
present for a diagnosis of substance dependence: 

1 . Evidence of tolerance, as defined by either of the 

a. A need for markedly increased amounts of the sub- 
stance to achieve intoxication or desired effects 

b. Markedly diminished effect with continued use 
of the same amount of the substance 

2. Evidence of withdrawal symptoms, as manifested 
by either of the following: 

a. The characteristic withdrawal syndrome for the 

b. The same (or a closely related) substance is taken 
to relieve or avoid withdrawal symptoms 

3. The substance is often taken in larger amounts or 
over a longer period than was intended. 

4. There is a persistent desire or unsuccessful efforts 
to cut down or control substance use. 

5. A great deal of time is spent in activities necessary 
to obtain the substance (e.g., visiting multiple doc- 
tors or driving long distances), use the substance 
(e.g., chain smoking), or recover from its effects. 

6. Important social, occupation, or recreational activities 
are given up or reduced because of substance use. 

7. The substance use is continued despite knowl- 
edge of having a persistent or recurrent physical 
or psychological problem that is likely to have 
been caused or exacerbated by the substance (e.g., 
current cocaine use despite recognition of cocaine- 
induced depression, or continued drinking despite 
recognition that an ulcer was made worse by alcohol 

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A physical and mental state of exhilaration and 
emotional frenzy or lethargy and stupor. 

Substance Intoxication 

Substance intoxication is defined as the development of 
a reversible substance-specific syndrome caused by the 
recent ingestion of (or exposure to) a substance (APA, 
2000). The behavior changes can be attributed to the 
physiological effects of the substance on the CNS and 
develop during or shortly after use of the substance. 
This category does not apply to nicotine. 

DSM-IV-TR Criteria for Substance 

1 . The development of a reversible substance-specific 
syndrome caused by recent ingestion of (or expo- 
sure to) a substance. 

NOTE: Different substances may produce similar 
or identical syndromes. 

2 . Clinically significant maladaptive behavior or psycho- 
logical changes that are due to the effect of the sub- 
stance on the CNS (e.g., belligerence, mood lability, 
cognitive impairment, impaired judgment, impaired 
social or occupational functioning) and develop dur- 
ing or shortly after use of the substance. 

3. The symptoms are not due to a general medical 
condition and are not better accounted for by an- 
other mental disorder. 

Substance Withdrawal 

Substance withdrawal is the development of a substance- 
specific maladaptive behavioral change, with physi- 
ological and cognitive concomitants, that is due to the 



The physiological and mental readjustment that 
accompanies the discontinuation of an addictive 

cessation of, or reduction in, heavy and prolonged sub- 
stance use (APA, 2000). Withdrawal is usually, but not 
always, associated with substance dependence. 

DSM-IV-TR Criteria for Substance 

1 . The development of a substance-specific syndrome 
caused by the cessation of (or reduction in) heavy 
and prolonged substance use. 

2. The substance-specific syndrome causes clinically 
significant distress or impairment in social, occupa- 
tional, or other important areas of functioning. 

3. The symptoms are not caused by a general medi- 
cal condition and are not better accounted for by 
another mental disorder. 


The following 1 1 classes of psychoactive substances are 
associated with substance-use and substance-induced 
disorders. They include the following: 

1. Alcohol 

2 . Amphetamines and related substances 

3. Caffeine 

4. Cannabis 

5. Cocaine 

6. Hallucinogens 

7. Inhalants 

8. Nicotine 

9. Opioids 

10. Phencyclidine (PCP) and related substances 

11. Sedatives, hypnotics, or anxiolytics 


A number of factors have been implicated in the pre- 
disposition to abuse of substances. At present, no sin- 
gle theory can adequately explain the etiology of the 
problem. No doubt, the interaction between various 
elements forms a complex collection of determinants 
that influence a person's susceptibility to abusing 

Biological Factors 

An apparent hereditary factor is involved in the devel- 
opment of substance-use disorders. This is especially 
evident with alcoholism, less so with other substances. 

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Children of alcoholics are three times more likely 
than other children to become alcoholics (Harvard 
Medical School, 2001). Studies with monozygotic and 
dizygotic twins have also supported the genetic hy- 
pothesis. Monozygotic (one egg, genetically identical) 
twins have a higher rate for concordance of alcoholism 
than dizygotic (two eggs, genetically nonidentical) twins 
(Andreasen & Black, 2006). Other studies have shown 
that biological offspring of alcoholic parents have a sig- 
nificantly greater incidence of alcoholism than offspring 
of nonalcoholic parents. This is true whether the child 
was reared by the biological parents or by nonalcoholic 
surrogate parents (Choudary & Knowles, 2008). 


A second biological hypothesis relates to the possibil- 
ity that alcohol may produce morphine-like substances 
in the brain that are responsible for alcohol addiction. 
These substances are formed by the reaction of bio- 
logically active amines (e.g., dopamine, serotonin) with 
products of alcohol metabolism, such as acetaldehyde 
(Jamal et al, 2003). Examples of these morphine-like 
substances include tetrahydropapaveroline and salsoli- 
nol. Some tests with animals have shown that injection 
of small amounts of these compounds into the brain 
results in patterns of alcohol addiction in animals who 
had previously avoided even the most dilute alcohol 
solutions (McCoy et al, 2003). 

Psychological Factors 
Developmental Influences 

The psychodynamic approach to the etiology of sub- 
stance abuse focuses on a punitive superego and fixation 
at the oral stage of psychosexual development (Sadock & 
Sadock, 2007). Individuals with punitive superegos turn 
to alcohol to diminish unconscious anxiety and increase 
feelings of power and self-worth. Sadock and Sadock 
(2007) state, "As a form of self-medication, alcohol may 
be used to control panic, opioids to diminish anger, and 
amphetamines to alleviate depression" (p. 386). 

Personality Factors 

Certain personality traits are thought to increase a 
tendency toward addictive behavior. Some clinicians 
believe a low self-esteem, frequent depression, passiv- 
ity, the inability to relax or to defer gratification, and 
the inability to communicate effectively are common 
in individuals who abuse substances. These personality 
characteristics cannot be called predictive of addictive 

behavior, yet for reasons not completely understood, 
they have been found to accompany addiction in many 

Substance abuse has also been associated with anti- 
social personality and depressive response styles. This 
may be explained by the inability of the individual with 
antisocial personality to anticipate the aversive conse- 
quences of his or her behavior. It is likely an effort on 
the part of the depressed person to treat the symptoms 
of discomfort associated with dysphoria. Achievement 
of relief then provides the positive reinforcement to 
continue abusing the substance. 

Sociocultural Factors 
Social Learning 

The effects of modeling, imitation, and identifica- 
tion on behavior can be observed from early child- 
hood onward. In relation to drug consumption, the 
family appears to be an important influence. Various 
studies have shown that children and adolescents are 
more likely to use substances if they have parents who 
provide a model for substance use. Peers often exert a 
great deal of influence in the life of the child or adoles- 
cent who is being encouraged to use substances for the 
first time. Modeling may continue to be a factor in the 
use of substances once the individual enters the work 
force, particularly if the work setting provides plenty 
of leisure time with coworkers and drinking is valued 
as a way to express group cohesiveness. 


Another important learning factor is the effect of the 
substance itself. Many substances create a pleasurable 
experience that encourages the user to repeat it. Thus, 
it is the intrinsically reinforcing properties of addictive 
drugs that "condition" the individual to seek out their 
use again and again. The environment in which the 
substance is taken also contributes to the reinforce- 
ment. If the environment is pleasurable, substance use 
is usually increased. Aversive stimuli within an envi- 
ronment are thought to be associated with a decrease 
in substance use within that environment. 

Cultural and Ethnic Influences 

Factors within an individual